Skip to main content

Full text of "The examination of patients"

See other formats

:■:■ ■ (J pill j pi llipilll llllipill ; 


I us iij in 


■ ■ |j I ■ i ' ; 

liiil i !i i >mi ll . ; 



-»— S5n» 



BOOK 6 16.075. F8 15E c. 1 „____- 


■a qm nnm7rH3 M 

Digitized by the Internet Archive 
in 2013 

Examination of 


Nellis B. Foster, M. D. 

Associate Physician to the New York Hospital; Associate Professor 
of Medicine at Cornell University College of Medicine 


Philadelphia and London 


Copyright, 1923, by W. B. Saunders Company- 

Reprinted January, 1924 

Reprinted April, 1924 

Reprinted September, 1925 

MASS in rr. S. A-. 




"Why do doctors so often make mistakes? Because they are not sufficiently 
individual in their diagnoses or their treatment. They class a sick man under some 
given department of their nosology, whereas every invalid is really a special case, a 
unique example. How is it possible that so coarse a method of sifting should produce 
judicious therapeutics? Every illness is a factor simple or complex, which is 
multiplied by a second factor, invariably complex — the individual, that is to say, 
who is suffering from it, so that the result is a special problem, demanding a special 
solution, the more so the greater the remoteness of the patient from childhood or from 
country life. 

"The principal grievance which I have against the doctors is that they neglect 
the real problem, which is to seize the unity of the individual who claims their care. 
Their methods of investigation are much too elementary; a doctor who does not 
read you to the bottom is ignorant of essentials. To me the ideal doctor would be 
the man endowed with profound knowledge of life and of the soul, intuitively divin- 
ing any suffering or disorder of whatever kind, and restoring peace by his mere 
presence. Such a doctor is possible, but the greater number of them lack the higher 
and inner life, they know nothing of the transcendent laboratories of nature; they 
seem to me superficial, profane, strangers to divine things, destitute of intuition and 
sympathy. The model doctor should be at once a genius, a saint, a man of God." 
(The Journal Intime of Henri-Frederic Amiel, Scheveningen, August 22, 1873.) 



This book has been written in the belief that it will help prac- 
titioners of medicine. Its aim is to present as clearly and con- 
cisely as possible, methods of determining the facts on which 
accurate diagnosis rests. For the most brilliant discoveries in 
therapeutics or the most skillful surgery avail nothing if the 
patient's disease is not correctly diagnosed. Experience in hos- 
pital and private practice has impressed upon me the need for 
such a book to furnish an intermediary between the classical 
description of the textbook of medicine and the treatise on the 
latest methods of treatment. Refinement of diagnosis compels 
the use of the trained senses of touch, sight, and hearing. The 
development of laboratory methods has diverted attention from 
these fundamentals. Those of us who have lived in laboratories 
as well as hospital wards may realize this fact, but the realization 
is not general. Rarely can a laboratory test alone reveal the 
nature of disease. Usually it is a support to other evidence — a 
bit of data like other signs to be weighed in forming opinion. 
Not even a throat culture which is positive for Klebs-Loffler bacilli 
is alone sufficient to demonstrate that an individual has diphtheria; 
he might be a carrier, or the organism might be non-pathogenic. 

It has been a matter of doubt in my mind whether I can de- 
scribe methods which I have taught for years by demonstration. 
But I have faith that the earnest worker will make up for any 
deficiency by practice. A refined technique is always a product 
of the individual. 

Nellis B. Foster. 

New York. 



„ _ Paqb 

The Theory of Diagnosis 17 

The Assembling of Data 20 

Anamnesis — The Clinical History 20 

Outline for Taking Case Histories 24 

The Physical Examination 30 

Examination of the Head 35 

Examination of the Thorax 40 

Examination of The Cardio-vascular System 44 

Examination of The Pulmonary System 47 

Examination of the Abdomen 52 

Examination of the Extremities 54 

Outline for General Routine Examination 56 

System Examinations 61 

Diseases of the Respiratory System 61 

Diseases of the Cardio-vascular System 76 

Diseases of the Digestive System 117 

Diseases of the Genito-urinary System 144 

Rectal Examination 148 

Gynecological Examination 152 

Neurological Examination 160 

Examination of the Eye . 163 

Acuity of Vision 163 

The Pupils 163 

Nerves of the Eyes 165 

Diplopia 166 

Conjugate Movements 168 

Ophthalmoplegia 169 

Ophthalmoscopic Examination . 170 

The Visual Fields 173 

Cranial Nerves 177 

Examination of the Motor and Sensory System 187 

Tests for Muscle Co-ordination 193 

Gait 194 

Reflexes 196 

Testing Sensation 199 

Convulsions and Coma 201 

Lumbar Puncture 207 

Examination of the Ear and Throat 212 

Examination of Joints and the Extremities 218 

Examination of the Breast 227 

Immunological Tests 232 

Tuberculin Tests 232 

Schick Test 235 

Index 239 



Heart Diseases 153 per hundred thousand population 

Pneumonia 149 per hundred thousand population 

Tuberculosis. 146 per hundred thousand population 

Pulmonary Tuberculosis 128 per hundred thousand population 

Nephritis 107 per hundred thousand population 

Apoplexy 82 per hundred thousand population 

Cancer 81 per hundred thousand population 

Enteritis 79 per hundred thousand population 

Arterial Diseases 25 per hundred thousand population 

Influenza 17 per hundred thousand population 

Diabetes Mellitus 16 per hundred thousand population 

Typhoid Fever 13 per hundred thousand population 

Measles 14 per hundred thousand population 

External Causes 108 per hundred thousand population 




Disease causes changes in subjective sensations (symptoms) — 
and in objective manifestations in the tissue of the body (signs). 
For the recognition of a disease entity we depend upon the correla- 
tion of these signs and symptoms into complexes which are often 
characteristic of a definite disease. For example, subjective malaise 
in association with objective fever, rose spots, and enlarged spleen 
usually indicates typhoid. This process of correlation of data into 
concrete conceptions began in man's remotest history as exemplified 
by the early recognition of devastating epidemics. But a system- 
atic study, which is the method of science, received its great 
impetus from Morgagni who endeavored to compare the record 
of symptoms during the life of the patient with the changes 
found in the organs after death. Morgagni's " Seats and Causes 
of Disease Investigated by Anatomy," published in 1760, marked 
the birth of pathological anatomy, and afforded a scientific 
basis for clinical medicine. When Morgagni showed that certain 
symptoms during life were associated with consolidation of the 
lungs or a pleural effusion demonstrated by autopsy, clinicians 
at once sought means for the recognition of these changes before 
death. The first of these methods of diagnosis evolved 
was percussion (discovered by Auenbrugger) and a few years 
later auscultation (by Laennec). The visible peculiarities of 

disease were, of course, noted in earliest times, and some of the 
2 17 


ancient physicians were most remarkable for the " seeing eye." 
Palpation developed possibly out of the earliest therapeutic 
ritual of the tribal medicine man: the laying on of hands. It 
becomes evident then that the theory of diagnosis is in no essential 
degree different from the theory of natural science in general. 
Phenomena detectable during life are seen to have been associated 
constantly with organic changes observed postmortem. From 
one set of facts the other may be predicted. The basic principle 
of all science is the same. Kepler observing a planet, recording 
its position at intervals and noting that the variation in this 
position marked a curve; finding a mathematical expression 
for the curve, from this curve predicting the future position the 
planet would occupy at intervals of time, employed the same 
principles as Mendel hybridizing peas, noting that of the resultant 
flowers one resembles one parent, one the other, and two a mixture 
of both. Always the process of method is the same, assembling 
data; analysis, induction. 

The first step, whether in the attempt to determine the cause 
of sickness in an individual or the nature of a new disease, is 
the collection of data. In clinical medicine these data consist 
of a record of the subjective symptoms of the patient and the facts 
secured by examining the patient. Assembling these data 
for diagnosis is scientific and may so be only in the sense that an 
orderly and systematic method is pursued. Securing the data 
is very largely an art. It is an art to secure a complete and 
accurate history of a patient's sickness. While subject to the 
laws of logic, securing the history of the patient is much the same 
as cross examination of a witness by an acute lawyer. And 
the physical examination is wholly an art. The accuracy of the 
observations made depends entirely upon the technical proficiency 
of the physician. Knowledge of the significance of physical 
signs alone is useless unless it be combined with the technical 


expertness to detect these signs. There is a close analogy between 
clinical medicine and music. One may know harmony, counter- 
point, and all that makes up the science of music, but unless 
by dint of practice he has mastered technique there will be 
no music. Technique in music produces beauty of tone; 
in medicine it secures accuracy of data. There are many sources 
of error in diagnosis, such as errors of judgment, errors in analysis, 
errors in data, but the commonest of all are errors of technique. 

Diagnosis is then a science and an art; a science in the method 
of using facts secured, an art largely in the mode of collecting 
the facts. 



Why is it customary to secure from the patient a history 
of his subjective symptoms? Certainly such a record is not 
always indispensable for diagnosis, since correct diagnosis is often 
possible when no history is obtainable, as the records of any large 
hospitals will demonstrate. But when the history furnishes no 
clue even the general nature of the patient's disorder is concealed. 
The clinician works in the dark and at a disadvantage. Unneces- 
sary time is lost and fruitless investigations made perhaps before 
the first clue is discovered. The following case is an illustration: 

A young man in coma, was brought into the New York Hospital from a 
sailor's lodging house. No history was procurable. There was fever up 
to 103 F. during the first day with elevation of pulse rate and respirations. 
There were no evidences of any injury. It was noted that a slight divergent 
strabismus of the right eye existed, that the neck was stiff and all muscle 
groups were hypertonic; the reflexes were present and there was no paral- 
ysis; there was no evidence of otitis media. Examination of the heart and 
lungs disclosed nothing abnormal. The spleen was palpable and on per- 
cussion slightly enlarged. Purulent urethritis was present, due to the 
gonococcus it was determined. The special examination of blood and urine 
yielded no significant fact. Thus far the facts indicated some infection with 
an involvement of the central nervous system. Especially considered were 
gonococcus septicaemia, with meningitis, tuberculous meningitis, typhoid 
with meningitis, and some form of poisoning. Blood cultures were made, 
a lumbar puncture performed and the fluid examined, radiograms of the 
skull to exclude fracture, the stomach and bowel lavaged, and chemical 
tests of the blood started. On the evening of the day of admission of the 
patient, his pal came to the hospital hunting his friend. From him we 
learned that they belonged to a tramp merchantman and the last port of 
call had been in Central America, also that the patient had had chills on the 
voyage north. A diligent search of blood slides disclosed an occasional 
malarial crescent and vigorous quinine therapy cured the patient. 



The value of a history here is obvious. Had one never been 
secured what are the probabilities? First, and most important, 
the patient would have died. It required the careful scrutiny of a 
number of blood-films before a malarial plasmodium was found. 
The hunt would not have been instituted till later, if at all, and 
then the discovery would have been useless therapeutically. 
Next, there was found a slight increase in the cell count in the 
cerebrospinal fluid which, with the other signs, pointed to a 
meningitis; the report later of a positive Wassermann reaction 
would have seemed to banish all doubt. Had the patient died 
what would have been the anatomical diagnosis in the morgue? 
That would have depended on whether sections of the brain 
were carefully studied and smears made from the spleen. No 
human routine can cover every contingency. The limits of time 
and the moral mandate of economy require that easily ascertained 
direction for effort can not be ignored. Then, too, it must not be 
forgotten that in some diseases all the facts obtainable are con- 
tained in the patient's account of himself — some psychopathic 
states. Even angina pectoris may be devoid of signs or demon- 
strable evidence. 

The clinical record of the patient's symptoms is customarily 
written in a definite arrangement beginning with the chief com- 
plaint and ending with a description of the present illness. The 
form is stereotyped, but there can be nothing stereotyped in the 
process of securing a good history. A man consults a physician 
because he is sick or believes he is sick. His attention has been 
focussed by some sensation: diplopia, perhaps, or palpitation or 
fever. And it is a fair guess that anxiety concerning his health is 
no small element in his consciousness. The human reaction in 
him is exemplified in his desire to relate his experience to one who 
will, he believes, be able to interpret it, and hence to relieve him. 
His interest is in his present state not his past health nor his 


family health. Common sense dictates that he be permitted to 
tell of his sickness in his own way undisturbed by deflecting ques- 
tion. Notes should be made of salient facts and dates as the 
patient proceeds, and when he is done, these memoranda serve the 
physician as a basis for further questioning on obscure or incom- 
plete details. It not infrequently happens that an episode of no 
moment in the estimation of the patient is, to the acute physician, 
a salient fact. Cross questioning clarifies, secures sequence and 
helps toward estimation of the important facts. But the direct 
question must be avoided. It is prone to mislead and distort 

Nor should a complete history be an invariable rule, at least in 
the beginning. When an individual is seriously ill and in distress, 
as from pneumonia, common sense indicates that only the 
absolutely essential facts be secured from the patient. What 
can not be supplemented by a member of the household should 
wait a better opportunity. The immediate record must be limited 
to a few notes concerning the present sickness. Tact and common 
sense must guide clinical enthusiasm. 

Everyone learns, in some degree, how to make a word serve 
the duty of a sentence. It is a most useful art in medicine and 
every student cultivates it. Descriptions are not of necessity 
clear because they are long. Completeness and conciseness are 
the aims sought. 

A complete clinical record is a narrative of an individual's 
state of health. It will tell whether this individual was, in general, 
robust or the contrary; whether he lived in an environment 
beneficial or deleterious; whether his habits were unwholesome; 
whether he came of a healthy family, or whether he inherited 
disease or a predisposition to it. This much is obvious and trite. 
But there is another aspect usually overlooked. An individual 
is a product of two major factors : his antecedents and his environ- 


ment. While we may sometimes learn from the family history 
of heritable disease, which is important, we can always learn the 
character of the stock from which the individual is derived. 
That parents and relatives attained a ripe old age in itself signifies 
something in contrast with forebears who died in early life. 
Every breeder and nurseryman differentiates strong and weak 
strains. In human life the fact is not less apparent though 
overlooked. The family history is first a record of the germ plasm. 
It may disclose also heritable disease or tendencies. There is no 
" negative" or " negligible" family history. 

In this biological sense the record of the health of an individual 
is a record of his reaction to his environment. Physicians have 
always recognized differences in individuals in their health ten- 
dencies, some are more vulnerable and susceptible. " Everyone 
has had tuberculosis;" many never knew it, and some succumb. 
Even in the same environment individual differences are apparent. 
These are the factors of physical personality, and between them 
and environment are reactions which influence invariably the 
organic life of the individual. Not in a purely physical sense only 
is environment a factor, but in mental states also. Witness the 
phrase description of certain neuroses — " maladjustment," and 
"inability to adjust to environment." 

Much of importance in the narrative of a patient may be read 
between the lines. In the way he expresses himself both his degree 
of intelligence and education are indicated. His choice of word 
and phrase; restraint or lack of it, the flow of his ideas, their tone, 
gestures, all help to an insight into emotional make-up and moral 
tone. It is all quite evident if the observer but observes. 

And of what value is this extra effort in case taking? It gives 
a whole picture rather than a sketch. We find out not only the 
disease which is the cause of immediate symptoms but we learn 
also the type of organism represented in the patient — his indi- 


viduality — which will in great or less degree in turn influence the 
course and manifestations of the disease. Disease is a reaction 
and reaction implies two agents: the patient and his disease. A 
clinician should know both. 

The following outline is one used in several large clinics and has 
been well tested : 


Note whether history was obtained from the patient or relative, 
friend or physician, in whole or in part, its reliability and the 
mental condition of the patient as evidenced by his answers. 
Next the chief complaint in the patient's own words, fully de- 
scribed (not diagnosis). From this point the history should be 
taken as pencil notes in the order which follows. Only when this 
provisional history has been reviewed and corrected, should it be 
recorded in its permanent form. The order for recording the 
history differs from that of obtaining it. 

Present Illness. — First ask the patient to tell you briefly the 
story of his illness in his own words, before taking notes. With 
this as a basis determine by direct questions the date of the first 
discoverable departure from health and initial symptom. The 
procedure will then differ materially in different types of disease. 

i. In Acute Infections or Intoxications. — Determine definitely 
the presence of an incubation period, its duration and symptoms; 
of an abrupt or gradual invasion, its date and exact interval 
before seeking advice, with the symptoms of the invasion period, 
such as chills, fever, sweats, general pains, headache, gastro- 
intestinal disturbance, cough, regional pain, or any other general 
or local symptoms; the subsequent course and symptoms in 
chronological order; the date when the patient was forced to stop 
work and the date when he took to bed; any treatment received; 


whether the patient's condition is growing worse, improving or 

2. In Chronic Illness. — The method of procedure must vary 
with the disease and mentality of the patient. A particular 
effort should be made to obtain from the family or friends any 
facts which will throw additional light on the history. It is 
usually well to note first the chronological development of symp- 
toms as observed by the patient, the date of stopping work 
or of any material change in his mode of life made necessary by 
his disease, and the symptoms responsible for this, such as dysp- 
noea, or pain of some kind, or weakness. When the symptoms 
point conspicuously to disturbance of a particular organ or system, 
proceed next to questions as to all possible symptoms referable to 
this system. Then obtain definite positive or negative answers 
as to the symptoms specified under the various systems below. 

With patients whose symptoms occur in attacks separated by 
intervals of freedom, it is necessary to obtain first a history of a 
typical attack; onset, duration, close, and the symptoms asso- 
ciated with it, i.e., pain, chill or fever, jaundice, haematuria, 
dyspnoea, etc. This account should be of the most recent attack, 
because it will be the best remembered. Then determine any 
differences presented by other attacks. Next ascertain if the 
occurrence of the attacks has any relation to any bodily function 
or environmental influence, such as eating, defecation, micturition, 
physical exertion, emotional excitement, time of day or season, 
etc., and their time relation to it. The patient's statements of 
causative factors should not be accepted except as a basis for 
investigation. Also question as to what has been found to relieve 
the attack. Finally note the intervals between attacks, especially 
between the more recent ones, and whether regular or irregular, 
increasing or diminishing. Note treatment received, and whether 
the condition is growing worse, improving or stationary. 


3. Li the Acute Complications of Chronic Disease. — First 
determine the time and mode of onset of the acute condition 
for which the patient seeks relief, with the subsequent course 
and symptoms, and treatment already received. Then pro- 
ceed with the history of the underlying disease as with chronic 

After this proceed to: 

Family History. — Obtain a specific statement regarding the im- 
mediate family — father, mother, brothers and sisters; a note as to 
their age, condition of health, if living; the age and cause of death, 
if dead. Obtain a specific history regarding tuberculosis, malig- 
nant disease, arthritis, goitre, heart and kidney disease, obesity 
and nervous affections. In certain cases obtain the family history 
of the grandparents, uncles and aunts. 

Past History. — First a statement regarding the patient's 
general health. A specific statement regarding the acute infec- 
tions, noting first the diseases of childhood, with special reference 
to measles, whooping-cough, mumps, scarlet fever, diphtheria, 
rheumatic fever, chorea; also malarial fever, typhoid, pneumonia 
and pleurisy. The infections not mentioned are to be stated 
if there is a history of them, but a specific statement is desired 
regarding those given above in all cases. Where there is a history 
of any one of these infections, it is desired that there be full 
notes regarding its duration, severity, complications, etc.; for 
example, with scarlet fever, if there was ear trouble or nephritis; 
with a history of "rheumatism," as to whether the patient was 
in bed, how long, the condition of the joints, fever, etc. 

Follow this with a Review of the Systems of the body in the 
order given below. The object of this review is to make sure 
that no symptoms have been overlooked which would indicate 
either past or pre-existing chronic disease, or a longer duration 
of the present illness than the patient has recognized. If this 


has already been discussed under Present Illness, enter here 
only those points not directly concerned in the story of the Present 
Illness. Under each system note only positive answers, and 
state "otherwise negative." Head: Note as to headaches, 
eye, ear (pain, deafness, discharge), nose or throat trouble, 
tonsillitis, quinsy, tooth abscesses. Cardio-respiratory: Chronic 
cough, morning cough, bronchitis, expectoration, hemoptysis, 
night sweats, pleural pains, oedema, shortness of breath, 
palpitations, etc. Gastro-intestinal: Appetite and digestion, condi- 
tion of bowels, noting number of movements a day, jaundice, 
vomiting, bloody vomitus, blood in stools, presence of piles, 
abdominal pain, relation of pain to eating, etc. Genito-urinary : 
Any disturbance of urination, pain, frequency of micturition, 
especially at night, polyuria or oliguria, haematuria, gonorrhoea 
(pain or discharge) and syphilis, with careful inquiry as to primary, 
secondary, and tertiary lesions. Nervous: Convulsions, paralysis, 
disturbances of speech or of gait, twitching or tremor; attacks 
of unconsciousness or faintness; dizziness. Mental changes, 
especially in memory or disposition, morbid fears, indecision; 
irritability, drowsiness, sleeplessness, fatigability. Pains, espe- 
cially neuralgic and lightning pains, paras thesiae. Vaso- motor 
and trophic disturbances. Locomotor system: Pain, tenderness, 
deformity or disability of joints. Bone pains or deformity. 
Muscular pain, lameness or weakness. Skin and appendages: 
Eruptions, pigmentation, thickening, loss or overgrowth of hair 
in any region, changes in nails, external tumors. Sweating or 
dryness. Menstrual history: If the patient be a female. Marital 
history: If the patient be married, add a note as to the number 
of years married, the number of children and their ages, their 
health, the number of miscarriages the patient or the patient's 
wife has had. Surgical operations and accidents are to be inquired 
into and noted under the appropriate system. 


Habits and Environmental Influences. — (i) Use of tobacco, 
alcohol or drugs. Always obtain specific statements as to amount 
used, whether previously or at present, habitual, periodic excess, 
or occasional, and age of beginning and discontinuing the habit. 

2. Habits of eating. Regularity of meals; amount and kind 
of food eaten; rapid eating; excessive use of particular articles of 
diet, sweets, meat, condiments, salt; habits of water drinking. 

3. Habits of sleep. 

4. Habits of exercise and recreation. 

5. Sexual habits in appropriate cases. 

6. Work. Character of occupation. Hours of work, day or 
night, regularity. Physical or mental strain and exposure to cold, 
heat, dampness, dust, environment, ventilation, overcrowding, 
speeding up, uncongeniality, etc. In any industry or trade where 
possible exposure to mineral dust, metallic or other poisons exists, 
inquire especially as to this, and as to cases of illness among 
other employees. 

In children. School hours, environment and aptitude. 

7. Home. Location and environment where of importance, 
as in malaria, hook-worm disease, bronchial asthma, etc., noting 
the conditions bearing on the patient's illness. Character of 
home. Sources of worry or infelicity. 

8. Sources of infection: In appropriate cases a careful inquiry 
into water and milk drunk, food eaten, and other sources of 
typhoid, trichiniasis or gastro-intestinal infections; contact 
with tuberculous individuals in home or shop; exposure to any 
communicable disease; sources of accidental infection with 
syphilis; residence in the tropics or in regions where malaria, 
hook-worm, filariasis, echinococcus, etc., are known to exist. 

Weight. — Note as to average weight; best previous weight, and 
date; weight before onset of present illness; and note as to any 
progressive gain or loss of weight. 


The following order is the usual one employed in recording 
the history: 

1. Name, etc. 

2. Source and Reliability of History. 

3. Chief Complaints. 

4. Family History. 

5. Past History. 

6. Habits and Environmental Influences. 

7. Present Illness. 


Disease is accompanied by changes in the function and in the 
structure of tissues. Infection is associated with reactions in the 
infected individual, one of the most conspicuous being an increase 
in heat production and radiation which is manifested by a rise in 
body temperature, fever. The reaction to local infection is 
inflammation which in a superficial part is characterized by 
increased warmth to the touch, redness to the sight, and a change 
in the consistency of the tissues in the involved region, vascular 
engorgement, edema. The area involved is harder than the sur- 
rounding tissue, and perhaps pressure with the ringer leaves a transi- 
ent indentation, a pit. Subjectively to the patient this inflammation 
is painful, and if it be in or near a joint the function of the limb 
is impaired. Now the detection of these signs is physical diagnosis 
and it depends primarily upon the skilled use of the special senses, 
and secondarily to some degree upon the employment of various 
instruments and methods. The interpretation of the abnormali- 
ties discovered rests upon a knowledge of pathology. The first is 
purely an art, and like all arts for its employment requires a 
refined technique, to be gained only by practice and experience. 
But the great diagnosticians have not only mastered this art but 
each one has also had an experience in the morgue which made 
him familiar with morbid anatomy. 

Since diagnosis depends upon pathology which is scientific in 
method, and the data for pathological interpretation in the living 
subject come through the use of the senses, it becomes evident 
that there are fruitful sources of error. The senses are easily 
deceived. This is the reason that the history of clinical medicine 
in the last century is demarked by the development of instru- 




ments and methods designed either to correct sense impressions or 
to supplant data obtained through them. But neither instru- 

Fig. 1. — Achondroplasia. 

Fig. 2. — Cretinism. 

ments nor methods have or can dispense with experience and judg- 
ment; and " experience is fallacious, judgment difficult. "* 

* Hippocrates. 


The commoner sources of error which the clinician keeps in 
mind are: (a) incomplete data, and from this resulting mistake 
in judgment. For example, a child has signs of coryza, Koplik's 
spots are overlooked because not looked for. The immediate 
diagnosis is judged to be coryza, but later a correction of the error 
is required, (b) Misinterpretation of data: sudden pain in the 
abdomen; fever; muscle spasm of the right side of the abdomen, 
leukocytosis, no abnormal signs in the chest, interpreted to mean 
acute appendicitis requiring surgical measures. The day after 
operation definite signs of consolidation are noted in a lung. 
This is a common error of internist and surgeon alike, (c) Faulty 
data: symptoms and signs of pyelitis, enlarged kidney, radiogram 
negative for stone, diagnosis pyelitis, later renal colic and passage 
of uric acid stone. 

Of these commonest sources of error the most frequent is 
incompleteness of data. There is no question that fewest mistakes 
are made when the study of the patient is most complete. But 
an ideal completeness is never possible, time, monetary consideration 
for the patient, and a humane regard for unnecessary pain impose 
their limitations. Consider the effect of a routine lumbar puncture 
in every case. A routine examination can be conducted, however, 
well within imposed limitations which will be not only sufficiently 
searching to discover common abnormalities but also will detect 
clues to be traced down by more elaborate and detailed study. A 
man enters the hospital complaining of headache and deafness in 
one ear; the general examination reveals abnormalities in his pupils, 
his hearing, heart sounds and reflexes. Syphilis is suspected, and 
by special study of blood and cerebro-spinal fluid this is confirmed. 
In examination of the patient, in general, the progression is logical 
from the general to the particular: first an infection, next its type; 
or a gastro-intestinal disorder to pyloric ulcer; or a disease of the 


cardio -vascular system which reveals itself as myocardial 
degeneration with auricular fibrillation. 

In order that the general examination discover abnormalities 
and clues to concealed abnormalities there must be care, system 
and order. Too often it is forgotten that the demonstration of 

Fig. 3. — Cretinism and Frohlich syndrome. {Case of Professor Schloss.) 

one disease does not exclude another. Tabes may be overlooked 
because of obvious typhoid fever. And system must become for 
the clinician a habit, a " fly-wheel;" it is his aid not his master. 
Cases of obscure or complex diseases most require systematic 
general examination in order to detect slight clues easily over- 



looked. Invariably one begins with inspection. Unconsciously, 
perhaps, significant features are noted at first glance, the appear- 
ance of health or disease; vigor or weakness, nutrition, color; 
the facial expression of ease or discomfort. These aspects are 
noted at once before the patient states the reason for the consulta- 
tion. Consider the disorders which are apparent by simply 
watching an individual. Acromegaly, rickets in children, oxyce- 
phalia, chorea, Graves' disease, cretinism, achondroplasia, paralysis 

Fig. 4. — Rickets showing "rosary." 

agitans, congenital syphilis, and many others — the street-car 

diagnosis in which every student delights. 

There are two essential conditions for a proper inspection of a 

patient, good light* and the patient well exposed. The patient 

should be covered by a sheet only, which may be adjusted to 

the convenience of the examiner. 

* Jaundice is obscured by artificial light unless "daylite" glass is used. 



Logically examination begins with the head since various facts 
are noted during the period of taking the patient's history, the 
character of the fades, healthy or ill, in pain or at ease, anxious or 
placid, dull or alert; their color; flushed, pale, cyanotic, pigmented; 

-■• .".;- 

Fig. 5. — Graves' syndrome. 

signs of oedema, paralysis, or change in bone framework. At the 
same time is noted some more general facts, the nutrition and 
decubitus. There may be abnormality in the shape or size of the 
head, for example in children the rachitic head; the hair and its 
distribution on the forehead and in the eyebrows. Next examine 


the eyes, noting movements of the lids, ptosis and nictitation, prom- 
inence of the globe or exophthalmus, and if the latter be present 
make the special tests (von Graefe's and Stellwag's signs) ; test for 
nerve involvement of the extraocular muscles by having the patient 
follow the examiner's finger up and down, to right and left; look 
at the sclera and note the color, whether white, jaundiced, pig- 
mented, abnormal in lipoid deposits, or injected, ' The pupils are 
examined to detect deviations from the normal in size (myosis, 
mydriasis) ; in shape : their outline whether circular or distorted by 
scars (lues); inequality (anisocoria is found in 10% of normal 
persons) and their reaction during accommodation and to light 
(Argyll-Robertson) both directly and consensually since disorder 
in the consensual reaction is an earlier manifestation of disease 
than the direct reaction. Notice the cornea for opacities and scars 
(lues, " rheumatic infections"). Amaurosis can scarcely escape 
detection; and the patient will probably have observed diplopia 
but hemianopsia is often disclosed only by test. A rough test 
can be made of each eye (the visual field) by directing the patient 
to look at the examiner's nose. Then the examiner's finger is 
brought into the field of vision and moved to the right, left, up and 
down, noting when it becomes lost to the patient. Photophobia 
will be obvious and vision tests required in special cases. The 
modern ophthalmoscope is so easy to use and the results of exam- 
ination often so significant that this aid can not be neglected, 
particularly in any case of chronic headache or obscure disease. 
Frequently it has happened that the picture in the fundus of 
the eye in nephritis was found more definite than the results of the 
most elaborate functional tests. Examine for opacities in the 
media, signs of thickening in the arteries, haemorrhages, exudate, 
choroiditis, retinitis, and abnormalities in the disc. 

The ears should be examined for deformities and tophi in the 
external ear, disorders in audition, discharge and tenderness. 



Use an otoscope for detecting depressed or perforated drum 

External deformity of the nose due to injury or disease (saddle 
nose) will be noted, in addition test each nostril for its patency, and 
if obstructed find the cause whether polyp, hypertrophied turbi- 
nate .or other disease. Ulceration and perforation of the septum 
are noteworthy. Pus may suggest sinus infection. In suspected 

Fig. 6. — Congenital syphilis, Hutchinsonian teeth. There was also interstitial 


disease of the central nervous system the sense of smell should be 

During examination of the nose and mouth the examiner 
becomes aware of any peculiarity of the breath: foul (ozena, 
bronchiectasis, pulmonary gangrene, carious teeth, gastritis), 
fruity ("acetone" — diabetes), or the uraemic odor. 

Any disorder of speech, suggesting defective innervation of the 
tongue and lips have been noted in the course of conversation. 


Dysarthria may be lingual with a clumsy and lisping articulation 
of S, Th, T and D, or labial (facial) with indistinct utterance of 
F, P and V. The dysarthria of post diphtheritic paralysis and 
syphilitic perforation of the palate is similar to that of congenital 

Fig. 7. — Epithelioma (basal cell). (Case of Howard Fox, M.D.) 

cleft palate; the voice is nasal, B sounds like M, and K becomes 

In examining the mouth take note not only of the tongue's 
coating and whether it be dry or moist, but observe also fissures, 
scars, dental marks of swelling, ulceration or thickening (epithe- 
lioma), leukoplakia, pigmentation, tremors or deflection in pro- 
trusion. Mucous patches are most often seen at the line of closure 
of the teeth and inside of the lower lip. When one notices the 
teeth observe if there are intact opposing molars sufficient for 
mastication, are there loose teeth, is pyorrhoea alveolaris marked or 



absent, are there characteristic deformities in shape (Hutchinso- 
nian) , in spacing (thyroid disorders) . Considerable enlargement of 
the tonsils is conspicuous, but a tonsil that appears small is not of 
necessity free of infection. In suspected neurological conditions 

Fig. 8. — Nodular leprosy. {Case of Howard Fox, M.D.) 

and neuroses test the pharyngeal reflex. In some diseases the 
larynx should be examined by aid of a mirror: in voice and speech 
defects, when aneurysm is suspected, and often with dilated heart. 
When syphilis is suspected atrophy of the follicles of the posterior 
part of the tongue is significant and detectable by the aid of a 


mirror. Slight hoarseness with pulmonary tuberculosis is often 
an early symptom of laryngeal involvement. 

In the examination of the neck the chief abnormalities to be 
sought are deformities due to torticollis or scoliosis; tumefactions 
from enlarged glands (tuberculous, Hodgkin's, sarcoma), cysts and 
abscesses; enlargements of the thyroid (goitre, Graves' disease, 
neoplasm), abnormal distention of the veins or arteries and the 
character of their pulsations, position of the trachea and the pres- 
ence of a tracheal tug. 


Technique. — For the detection of departures from the normal 
in organs and tissues of the thorax it is requisite that the examiner 
have knowledge of the topographical anatomy of the chest and 
also that he possess skill in the technique of palpation, percussion 
and auscultation. No mere direction can impart this skill 
which must be acquired by practice and experience in the method. 
At most some general directions for guidance toward a better 
technique can be given. 

Palpation. — By palpation in general we detect changes in the 
size, shape, consistency of structures, alterations in surface tem- 
perature, and transmitted vibrations. Palpation depends on the 
sense of touch and the muscle sense of strain when exercising 
pressure. Depending on the nature of the examination one 
employs for palpation the balls of the fingers, the whole length 
of the ringers or the flat hand. In palpating the chest to deter- 
mine the point of apex impulse of the heart the balls of the ringers 
are used, while in estimating fremitus the palm and fingers should 
be placed on the chest. The degree of pressure influences the 
impression felt. Thrills and fremitus are best felt with relatively 
light pressure while more may be required in estimating the force 
of abnormal impulses. 



Percussion. — By percussion are determined changes of den- 
sity in tissues or changes in the position of adjacent tissues when 



Fig. 9. — Papulo-pustular syphilide. (Case of Howard Fox, M.D.) 

these have different densities, as for example heart and lung. 
In percussing, the second ringer of the left hand (pleximeter 


finger) is held firmly on the chest wall and is struck just back of the 
nail with the end of the second finger of the right hand (plexor). 
Accuracy of data depends on (a) the pressure of the pleximeter 
finger, (b) correctness of force of the blow struck, (c) the position 
of the patient during examination. The commonest mistake 
among novices (and too many remain novices) is too light pressure 
with the pleximeter finger. There is no entirely reliable guide, 
but one that is of some help is the blanching of the skin. If 
one presses the finger firmly upon the normal skin and quickly 
withdraws it, there is left on the skin a fleeting blanched area. 
In percussion the pressure of the pleximeter finger should be 
firm enough to leave such a blanching. When the patient is sitting 
on a chair or stool before the examiner there should be a support 
for his back, otherwise the slight effort he makes to hold his 
position against the pressure of the examiner's hand while per- 
cussing induces an interfering muscle strain. The patient should 
be relaxed, in a comfortable posture and with the face looking 
forward. The position of the patient influences not only the 
technique in percussion but also the character of the percussion 
note whether resonant or impaired. This fact must always be 
taken into consideration when, because of the condition of the 
patient, it is necessary to roll him on his side rather than have him 
sit up for examination of the lower lobes of the lung. The charac- 
ter of the note induced in percussion is much influenced not only 
by the force of the blow but also the way it is struck. The 
movement in striking is a wrist movement entirely and involves 
what pianists call a "loose wrist." The plexor finger must come 
away after the blow like a rebound. Then the force of the 
blow must be varied with the nature of the examination. Heavy 
percussion brings out deep changes in density, but small areas 
are obscured by the resonance of surrounding tissue, while 
a light percussion detects only superficial change but is accu- 


rate for delimitation. Only critical practice can teach these 

Auscultation. — There is no technique per se in the act of 
auscultation. Everything rests on the recognition and inter- 
pretation of what is heard. Nor is there any difference in principle 
between using the unaided ear (immediate auscultation) and 
a stethoscope (mediate auscultation), each has its place. Nor 
is there any peculiar advantage in one type of stethoscope over 
another. The object is not to hear more sounds, all of us hear 
more than we can interpret, but rather to discriminate in what 
we hear. It is important that the ear pieces of a stethoscope 
fit the ear and that the lumen in the tubes have the direction of 
the external auditory canal when the instrument is in position. 
If the instrument purchased does not meet these specifications 
the tubes should be bent till it does. 

In examining the thorax an oblique light is often better than a 
direct one, since pulsations then appear as moving shadows. 
Excluding any striking sign, one takes note first of the respiratory 
movements, their rate and character, whether they are fast or 
slow, shallow or deep, regular or abnormal in type (e.g., Cheyne- 
Stokes, Biot), whether they are thoracic or abnormal. The 
shape of the chest is sometimes suggestive of past or present 
disease, for example the rachitic chest, the "phthinoid" chest, 
the barrel chest of emphysema, bulging of one side in pleural 
effusions, and the asymmetry of cardiac disease in early life. 
The texture of the skin and the distribution of the hair are altered 
in some diseases (status lymphaticus) . In women the mammae 
should invariably be palpated for areas of tenderness or change 
in the gland texture. 

* The student may get some notion of the significance of terms applied to per- 
cussion sounds by percussing his own chest (resonant), thigh (flat), the inflated 
cheek (tympanitic),, the cheek with the mouth slightly open (amphoric). 



Examination of the heart and vascular system should precede 
examination of the lungs, rather than in the opposite order because 
disorders in circulation explain signs found in the lungs more 
often than the reverse. Moreover deep breathing influences 
the heart rate. 

In the examination of the heart and vascular system generally 
the object is to determine (a) any abnormality; if there be an 
abnormality, (b) is this related to present symptoms and if not, 
(c) is it likely to be the cause of future symptoms. Any abnormal 
engorgement of the veins in the neck or pulsations of the vessels 
has already been noticed. Precordial heaving or retraction, the 
position of the apex impulse, and its character are important and 
confirmable by palpation. The significant data secured by 
palpation are (a) the position of the apex impulse, (b) the character 
of the impulse, localized or diffuse, weak or the heaving thrust 
of hypertrophy, (c) cardiac rhythm, (d) thrills and their time 
relation to the cardiac cycle. In timing thrills and murmurs* 
the systolic impulse should be taken with the fingers of the free 
hand from the carotid artery in the neck, never from the radial 
pulse since the latter is % second later than the systolic contraction. 
Next in order the pulse is noted to determine its rhythm, rate, 
tension, and character and whether the artery is thickened 
or not. 

* Timing murmurs is not always easy and in the case of mitral murmurs much 
depends on whether a murmur is systolic or diastolic. Riesman advocates a method 
which is helpful. It is designated as " transdigital auscultation." To practice it, 
it is necessary to use a diaphragm stethoscope. The index or middle finger is flexed 
at a right angle and the tip of the finger is placed directly over the apex impulse. 
The stethoscope is then laid on the horizontal phalanx of the flexed finger, at the 
angle. It will be found that murmurs may be heard nearly as well through the 
finger as when the stethoscope is placed directly on the chest. Since auscultation 
and palpation are performed at the same place one can tell whether a murmur 
occurs before the finger is lifted, synchronously with the lifting, or afterwards. 

The method serves also for eliciting Duroziez's murmur in the femoral artery. 


The facts secured by percussion bear upon the size and position 
of the heart and the diameter of the aorta. In practice the best 
method is to determine first the upper margin of the liver (deep 
hepatic dulness) since this with the point of maximum impulse of 
the heart gives a working base line. Determine then in order the 
right cardiac border, left border and the retromanubrial or (para- 
sternal) dullness. To determine the size of the heart by means of 
percussion is a test of technical skill. The usual mistake is to use 

Fig. io. — Sarcoma. 

too light percussion on the right side and too heavy on the left. 
On the left side a lappet of lung is interposed between the heart 
and chest wall, and this lappet increases in thickness toward the 
left cardiac border. On the right side this state of affairs does 
not exist there being a relatively sharp boundary between air 
containing and solid media. Accordingly, it is customary to 
percuss the precordium toward the midline; and on the left side 

4 6 


to decrease the force of the percussing stroke as the precordial 
area is approached. Also the pleximeter finger must rest in 
intercostal spaces; a stroke on a rib induces resonance from the 
whole thoracic framework. 

By auscultation information is secured bearing in the main 
upon the state of the heart muscle, the cardiac rhythm and the 



Day of Month. 

f."* <r 9 /a >i >^- '3 

Day of Illness. 

Hour of Day. 





p v 






■i <4 


$ 1- 



P /J 


p /•/j 




. 1 i . 

• • . . TEMP. 




■ ■ • • o 


: : : : : 





; c 

t j 


: : : : 

• 4 

■ « 

1 • 




• ■ -A. • 


" 'j 





: : ■ i : : 












* * 






k [ H 

: : i : 










: f 



; i ; 


: i 





I 1 



. . 



• i • 











. } ' 

\ A 














■i; " a 

L ' 98° 





•i ' 

f' : 


- . t . . i 

r . + — - VB 





• • < 


• 1 
; i ; 

<? : 

•^ 95« 

■n— ' — i-rl 






3 « 
< is 


1 * 






3 1 r 















9 » 







3 q$* 

«£l f 

Fig. ii. — Chart of ulcerative endocarditis. 

condition of the valves. In the past too much emphasis has been 
given to murmurs and as a result the idea is too prevalent that to 
detect a murmur is the chief end of auscultation. Murmurs have 
lost their preeminent place and due regard is given to other, some- 
times more important, considerations. The character of the first 


sound at the apex betokens something of the state of the myocar- 
dium, since it is in part a muscle sound. It may be more intense 
or weaker than normal, prolonged (blurred) or shortened. 

Abnormal rhythm is, for many at least, easier to interpret 
through sounds than by feeling the pulse. There are four areas 
examined by auscultation, (i) the point of maximum impulse; 
(2) inside the apex at the mitral area (IV interspace, 6 cm. from 
the midsternal line), and (3, 4) at the 2nd intercostal space and 
sternal margin both on the left and right sides. In certain 
cases it is also necessary to listen over the vessels in the neck. 
It is most convenient to finish the cardiac examination by making 
the blood pressure tests since this is an auscultatory method. 


In the examination of the lungs the same order is preserved 
from inspection to auscultation. During the examination already 
made any conspicuous departure from normal in the shape of the 
chest, depression of the clavicular spaces, muscle wasting, character 
or asymmetry of respiratory movements have been noted. Now 
without distraction these impressions are reviewed and corrected. 
Palpation may be required to confirm a visual impression. For 
example, doubt as to whether respiratory movements are syn- 
chronous on the two sides is dispelled at once when the hands are 
placed on corresponding areas on the two sides. Cognizance is 
taken of muscle tone since the pectoralis muscles are often more 
tense on the diseased side. Fremitus due to pleural friction 
may be observed, and the vocal fremitus is tested by having the 
patient repeat "nine-nine" or count while the chest is palpated. 

If possible, percussion should be done with the patient sitting 
directly facing the examiner. The patient should be entirely 
relaxed. By percussion are learned changes in the physical 
character of the underlying tissue; is it more dense (solid) than 


normal or less dense than normal ? The significance of changes in 
density is clinical interpretation. This interpretation comes from 
no one sign. Nor is there a definite force appropriate for per- 
cussion over the lungs. Percussion must be varied depending on 
what is sought. As a rule, however, the tendency is to percuss too 
heavily and thereby lose small areas of changed density in the 


Fig. 12. — Factitious urticaria (dermographism). {Photograph by Howard Fox, 


resonance of surrounding tissue. But this is a matter every one 
must learn for himself; experience is the only teacher. 

Comparing corresponding areas, the anterior chest is first 
examined, beginning at the third interspace on the midclavicular 
lines and proceeding upward. This is a reversal of the usual mode 


of progression from the apices downward, but experience in 
teaching has convinced me that the normal impairment at the 
right apex is more easily detected if one compares first areas 
normally nearly alike and progresses toward the normal differ- 
ences. In detecting, say tuberculous lesions, this method has an 
especial advantage. Differences in pitch (dull, flat, etc.) and 
quality (tympanitic, amphoric) are heard and the pleximeter 
finger at the same time gives a sense of degrees of resistance. 
After the anterior chest, the axillae and then the back is examined. 
In some cases it is desirable to measure the limits of the bases at 
full inspiration and expiration, thereby disclosing diminished 
function of one lung. The height of the diaphragm determined by 
percussion is significant in several diseases. 

The following experiments are of great help to the student, and they can be 
carried out by groups working on each other. The subject for examination should 
be in an erect posture, with all muscles relaxed. 

Fremitus. — Compare the two sides at apices and at bases, making first light 
pressure with the palating hands, then firm pressure. Note differences in inten- 
sity of fremitus with varying pressures. Next use two types of chest, one thick 
and well nourished, the other thin. 

Percussion. — Percuss muscle, the skull, the lung. Repeat, varying pressure 
of the pleximeter finger, then the force of the blow. 

With the eyes closed mark the lower border of the right lung at full inspiration, 
then at full expiration. 

Percuss corresponding areas at the second interspace making light pressure 
with the pleximeter finger on one side and firm pressure on the opposite side. Com- 
pare the notes elicited. 

Standing to one side of the subject percuss the first intercostal space below 
the clavicle, on the near side, and then on the far side of the chest. Note differ- 
ences in the percussion sounds elicited because the percussed points are not equally 
distant from the examiner's ear and because the examiner cannot adapt his plexim- 
eter finger to the two areas with equal facility. Then illustrate the proper method 
by standing directly in front of the subject and turning the pleximeter hand so as 
to adapt the finger to the two sides (like an elevator dial). 

Compare asymmetrical points on the two sides. ■ 

Compare asymmetrical points but with the pleximeter finger resting in an inter- 
costal space on one side and crossing a rib on the opposite side. 

Use first a single finger for pleximeter, then several fingers, and note inability to 
make equal pressure with all the fingers. Note dulling of percussion sound when 
all fingers rest on the chest. 


Percuss the right sternal margin at the second rib and then one inch outside the 
sternal margin, using a light stroke; notice the difference in the pitch and quality 
of the sounds. Then use a heavy stroke and note that the difference in the per- 
cussion sounds over the two areas is not elicited. 

Percuss the anterior aspect of the chest from below upward comparing corre- 
sponding areas on the two sides. Note the first change in sound elicited. If dul- 
ness be detected above the second rib, have the subject carry his shoulder upward 
and backward and observe whether this effects a change in the percussion note. 
Compare the two sides first below the clavicle and then above the clavicle and 
note any differences. 

Have the subject fold his arms, thus separating the scapula and bend the spine 
well forward. Percuss the back from below upward an inch lateral to the para- 
vertebral lines. Notice any area where the resonance is changed, and its differ- 
ence on the two sides. Next have the subject stand erect and observe the result 
in the signs elicited. 

Compare differences in the lower borders of the lungs at full inspiration and 
expiration. Notice where the lung excursion is greatest. 

Auscultation. — Experiment with types of breathing and their effect on the 
breath sounds, notice whether the subject's breathing is chiefly thoracic, abdominal 
or combined, and have him breathe with the mouth wide open and breathe quietly 
without hastening either inspiration or expiration. Demonstrate pseudo-granular 
breathing and cogwheel breathing by instructing the subject to breathe noisily 
with a costal type of respiration, and detect the disappearance of the signs when 
abdominal breathing is adopted. 

Study vesicular breathing by listening at the fifth space in the mid-axillary 
line. Notice (a) the relative length of inspiration and expiration, (b) the pitch 
of inspiration and expiration, (c) the quality of inspiration and expiration. 

Next study areas where the vesicular element in the breath sounds is lacking, 
over the manubrium and posteriorly over the seventh cervical vertebra, especially 
notice length, pitch and quality of inspiration compared with expiration. Detect 
differences in the intensity of expiration compared with inspiration in the two areas, 
front and back. Compare these sounds with those heard over the trachea. 

Listen over the temporal region and over the occipital area just behind the 
mastoid process. Compare constantly inspiration and expiration as to length, 
pitch and quality. Notice a change, especially of quality in these areas (amphoric). 

With a pencil mark the following points on the right side of the chest: (i) first 
interspace and right sternal margin, (2) first interspace lateral to the mid-clavicular 
line, (3) second interspace and right sternal margin, (4) second interspace lateral to 
mid-clavicular line, (5) third interspace lateral to mid-clavicular line. Auscultate 
these areas from (5) to (1) in order and notice the gradation from pure vesicular to 
a bronchial type of broncho vesicular breathing. 

Compare the breath sounds heard at the angle of the scapula with those at the 
base of the axilla on the same side. Observe the length of expiration and the quality 
of inspiration and expiration in these areas. 

Compare the breath sounds at the angle of scapula on the two sides and refer to 
a work on anatomy for an explanation of the difference in sounds. 

Compare the breath sounds heard in the supra-clavicular and infra-clavicular 
fossae on the two sides. 


Voice Transmission. — Have the subject repeat in a deep bass voice 999 while 
the observer listens at the angle of the scapula. First make considerable 
pressure with the bell of the stethoscope and then gradually diminish the 
pressure and notice under what degree of pressure the sound vibrations are best 
transmi tted. 

With care as to the proper degree of pressure on the stethoscope bell have the 
subject repeat 999 in an ordinary voice, then in a deep yoice. 

Compare the fremitus on the two sides (1) below the centre of the clavicles, 
(2) above the spine of the scapulae, (3) at the bases of the lungs. 

If possible compare the signs elicited in a thin subject with those elicited 
in a stout one. 

Notice how far down the spine the spoken voice is transmitted, and at what level 
whispered pectoriloquy disappears. Compare the whispered pectoriloquy at the 
scapular margins at the level of the fourth dorsal vertebra. 

By auscultation are determined (a) the character (intensity, 
duration of inspiratory and expiratory phases, pitch and quality) 
of the breath sounds, and (b) adventitious sounds (rales and 
rhonchi). As with percussion it is better to examine the chest 
from below upward toward the apices. The character of the 
breath sounds is first determined over the various areas, and then 
spoken and whispered voice conduction. If rales be present 
determine if they are dissipated by deep breathing (atelectatic 
rales), or by coughing. If adventitious sounds are heard which 
may be muscle sounds instruct the patient how to relax the 
shoulder and neck muscles. If there are no adventitious sounds 
it will be necessary in some cases to determine if rales appear with 
the inspiration following a cough. Sounds can be produced by 
bone articulations which may be mistaken for rales. These 
sounds may be differentiated by having the patient move the 
shoulder while holding the breath. Pulmonary examinations are 
of necessity tedious and the recording of signs detected is apt 
to be confused. For this reason a system of indicators have 
been devised. These marks may be quickly made on the chest 
with a skin pencil or on a chart as one proceeds with the ex- 
amination, and are an aid to accuracy in writing out notes 



The abdomen is inspected best by an oblique light which will 
bring out shadows. In acute disease the conscious attention is 
fixed upon the type of respiratory movement, rashes, and the shape 
of the abdomen. Abdominal respiration vanishes in acute inflam- 
mations of the peritoneum and occasionally in pneumonia. The 
shape of the abdomen may be significant; the sunken scaphoid 
abdomen of rapid wasting diseases, especially in children, and the 
full tympanitic abdomen of febrile intoxication. In chronic 
diseases attention is directed to inequalities in the shape of the 
abdomen, to tumor masses, peristaltic movements (patterns of 
abdominal tumidity). The appearance of the abdomen is an 
index very often of the severity or duration of disease. Fat is lost 
here first because it is most often present in excess. 

Inspection and palpation of the abdomen are supplementary 
and lead to a fused impression. Many surgeons understand the 
technique of abdominal palpation but few internists do. This 
is because the surgeon sees more " acute abdomens" while the 
internist thinks of changes in the size and shape of organs. If 
pressure on the abdomen causes pain the abdominal muscles become 
rigid. It will be impossible for the patient to relax completely 
once pain has been induced, therefore leave deep pressure to the 
last of the examination. First test the tone of the abdominal 
muscles with the ball of the fingers and the lightest pressure, much 
as one would feel the tenseness of a stretched rubber band. Deter- 
mine first if there be muscle spasm, if it be general or local, and its 
degree, and let this guide the order of the remaining examination. 
The liver and spleen are examined for enlargement, irregularity 
in shape and if palpable for the character of the surface. When 
ascites is present the edge of the liver can be best felt by ballotte- 
ment (dipping with the ends of the fingers) and this applies also 
to outlining some tumor masses, and occasionally to the gall 


bladder. Enlargement of the spleen is sometimes overlooked by 
palpating too near the costal margin. Deep tumefactions require 
for their detection bimanual palpation. One hand is placed under 
the patient and one on the abdomen, and while the patient takes a 
deep inspiration the opposing hands are gradually brought together. 
The right kidney can be felt in all thin persons in this way. 

The determination of fluid in the abdominal cavity is largely a 
matter of percussion (movable dulness) but some evidence can be 
gained from the shape of the abdomen and by eliciting a fluid 
wave. This manoeuvre is executed by placing the hand on one 
flank and tapping the opposite side sharply with the ends of the 
fingers of the other hand. Fat, atonic abdominal walls are apt to 
give this sign in the absence of fluid. Percussion is of use in 
abdominal examination in determining (a) the boundaries of 
organs, i.e., liver, spleen, occasionally the stomach, (b) the nature 
of a mass as to whether it is air containing or solid and its relation 
to air containing viscera, (c) the detection of fluid by shifting 

The external genitalia are inspected for malformations in 
development, ulcerations, scars (chancre), phimosis or discharge. 
The earliest skin lesion of pellagra is found on the scrotum. In 
men the testes are palpated to determine size, nodules of induration, 
especially in the epididymis (tubercle). Syphilitic lesions are 
usually in the testes. In cases of obscure gastro-intestinal or 
abdominal disease the detection of a tubercle in the testes has led 
to correct diagnosis. In women tuberculosis of the fallopian 
tubes is one of the earliest manifestations of tuberculous peritonitis. 
Herniae, either inguinal or femoral, are more easily detected when 
the patient is standing. When there is any indication of disease 
in the external genitalia, the prostate and seminal vesicles in men 
and the tubes and ovaries in women should be investigated. In 
disorders of obscure origin the examination is obligatory. 


The anal region is inspected for external haemorrhoids, scars, 
fissures and fistulae. A rectal examination is always required in 
cases of gastro-intestinal disorder and often in other selected cases. 


Any conspicuous deformity in the limbs has been noted during 
the course of examination. Hippocratic fingers, Heberden's 
nodes or the grosser deformities in the fingers produced by arthritis 
would arrest attention. Sometimes the occupation can be read 
in the hand, only two trades produce callus on the thenar eminence. 
Disease may manifest itself by characteristic deformities or lesions; 
acromegaly, luetic dactylitis, tetany, osteo-arthropathy of pul- 
monary disease, arthritis deformans, gout, et cetera. Tremor, con- 
stant or volitional, is notable; also wasting of a group of muscles, 
i.e., the interossei. The commonest disease of bone of the wrist 
and forearm is tuberculosis, in the arm and shoulder sarcoma. 
Finally, the epitrochlear and axillary glands are palpated for 
evidence of enlargement. 

The lower extremities are inspected for scars of ulcers on the 
tibia and pigmentation. The tibiae are palpated for areas of peri- 
ostial thickening or bony irregularity (luetic) and the loose tissue 
below the malleoli for edema. In cases of pain in the back or legs 
a careful examination for flat-floot is indicated. In children the 
local symptoms from osteo-myelitis may be obscured by the vio- 
lence of the constitutional reaction and the disease mistaken for 
typhoid fever. 

Examination of the nervous system must needs be the merest 
outline in the course of a general examination. As a rule attention 
is confined to a few reactions which would serve as clues in cases 
of the commoner disorders. The pupils and some of the cranial 
nerves are tested during the examination of the head. The 
superficial reflexes of most significance are the abdominal, 



cremasteric and plantar reflexes. The deep reflexes, such as the 
knee jerk and ankle clonus are important. Romberg's sign indi- 

Fig. 13. — Nodular syphilide (resembling psoriasis). (Case of Howard Fox, M.D.) 

Fig. 14. — Ulcerating gumma. (Case of Howard Fox, M.D.) 

cates ataxia of moderate degree. Earlier degrees of ataxia may be 
detected by watching the tendons of the dorsum of the foot while 
the patient stands with eyes closed. The irregular twitching con- 



tractions indicate incoordination of muscle groups. A working 
outline for the routine examination is the following: 


Give first the general description of the patient — race, phy- 
sique, nutrition. Describe character of breathing and note 
presence of cough and character of sputum. Describe general 

Fig. 15. — Epithelioma (basal cell). (Case of Howard Fox, M.D.) 

condition — evidence of pain, restlessness, tremors. Make a 
brief note as to the mental state. 

Describe the complexion, the color of mucous membranes 
and finger-tips, texture of skin, its moisture and temperature, 
and abnormalities of the hair. Note the presence of eruptions, 
scars, jaundice, cyanosis, pigmentation and oedema. 


Record gross abnormalities in the bony framework and shape 
of the head. Look for bony thickenings of skull. 

Test the extra ocular movements; size, equality and reaction 
of pupils. Note protrusion, ptosis, and arcus senilis. 

Look for tenderness over the sinuses and mastoids, and for 
nasal obstruction. 

Note aural discharge, tophi, and range of hearing ability. 

Examine teeth, gums, tongue, buccal mucosa, tonsils, and 

Examine the thyroid gland. 

Describe the thorax — general conformation, symmetry and 
respiratory movements. 

Inspect the precordium and describe abnormal pulsations, 
noting precordial bulge and heave. Carefully localize the apex 
impulse. Look for retraction of the apex. Palpate the pre- 
cordium and note the character of the impulses and the presence, 
location and time of shocks or thrills. Carefully percuss the deep 
and superficial dulness of the heart and the retromanubrial 
dulness, if present, recording the measurements. Auscultate 
over the precordium, especially at the valve areas, characterizing 
the individual sounds and noting the type, time, and direction 
of transmission of murmurs. 

On palpation, note the extent of movement and presence of 
friction or rhonchal fremitus. Systematically percuss the chest, 
both in front and behind, comparing the notes of the two sides 
and making a comparison with what you consider normal for the 
individual. Note the position of the lung bases and the extent 
of their respiratory excursion. On auscultation, carefully describe 
the breath and voice sounds, Listen for adventitious sounds 
before and after coughing, especially at the apices. Corroborate 
abnormal voice signs by testing the vocal fremitus. 


Endeavor to analyze the venous pulse. Inspect the arteries. 
Palpate both radial pulses, recording both volume and differences. 
Note the rate and regularity in force and rhythm, and describe 
the character of any irregularity. Describe the vessel walls 
and abnormalities in the pulse-wave. 

Fig. 16. — Pigmentation due to ingestion of phenolphthalein. (Case of Dr. Weiss.) 

Inspect the abdomen. Note whether it is normal in appear- 
ance, distended or retracted. State whether it is symmetrical 
or whether there are local prominences. Describe any eruptions 
or visible movements. On palpation, note whether there is any 
localized or general tenderness, any palpable mass, any muscular 


rigidity, either general or local. Describe the general character 
of the percussion note. Test for movable dulness in the flanks. 
If present, test for fluid wave. 

Palpate for the liver, and if felt, note the consistency, character 
of the surface and edge, position of edge, presence of tenderness. 
Palpate for the gall-bladder. Palpate for the edge of the 

Percuss out the upper and lower limits of the superficial 
dulness of the liver. If enlarged downward, note the distance 
in centimeters from the costal margin in the mid-clavicular line, 
and below the ensiform cartilage in the median line. 

Palpate for the kidneys. 

Record abnormalities in the genitalia. Look for the presence 
of herniae. 

Note the condition of the superficial and deep reflexes. Test 
for Kernig's sign. 

Test the mobility of the spine. Note presence of kyphosis, 
scoliosis, or lordosis of the spine. Look for signs of acute or 
chronic arthritis, clubbing of fingers, thickening of tibiae. Note 
general glandular system. 

Measure the systolic and diastolic blood pressures (instrument) 
and note abnormal arterial sounds. 

In every case, the urine must be examined. Note the color, 
the reaction, specific gravity, reactions for albumin and sugar, 
and microscopic examination of centrifugal ized specimen. 

In all febrile cases of doubtful origin, fresh blood specimens 
should be examined for malarial parasities and for leucocytosis. 
In all cases with apparent anaemia or glandular enlargement, 
examine a specimen of blood. In selected cases a complete blood 
count should be made. 

The above routine should be followed in all medical cases. 
In many instances as, for example, in neurological cases, a special 


line of inquiry will be necessary in taking the history and special 
tests followed in making the physical examination. 

Special examinations, such as rectal examination, ophthal- 
moscopic, laryngoscopic and fluoroscopic examinations should be 
made when indicated. 

Record all important findings, normal or abnormal, but 
not unimportant negative data. 


By the physical examination of the lungs changes of a physical 
character only are detected. There may be an increase in density 
indicating that the lung tissue is relatively solid, or there may 
be liquid, or there may be a marked decrease of lung substance, 
a cavity, or pneumothorax. These are changes all of a physical 
character. Their clinical significance depends on other facts 
secured in the examination of the patient ; the duration and mode 
of onset of the disease, the symptoms, fever, sputum, et cetera. 
An area of consolidation might be pneumonia, an infarct or a neo- 
plasm. The facts revealed by physical examination of the lungs 
do not constitute a clinical diagnosis, but form only a part of 
necessary data. By comparison of certain physical signs detected 
during life with the structural changes observed at autopsy 
there has gradually developed a mass of experience on which 
rests the interpretation of signs. , Each sign is usually open to 
more than one interpretation, and these different interpretations 
must be known. For example, it may be notable at first glance 
that a patient's respiratory movements are asymmetrical. The 
left side moves conspicuously more than the right. Perhaps also 
the right side looks larger and fuller, more voluminous, than the 
left. Now this appearance may result from any one of several 
causes. The right pleural cavity may be full of fluid, either a 
pleurisy with effusion, empyema or hydrothorax, or there may be 
a massive consolidation of the whole right lung or, again, right 
pneumothorax may be the cause. Some of these possibilities can 
be excluded by the character of the percussion, others by the 



breath sounds and so on. The nature of a physical change in 
the lungs is indicated then, not by a single sign but by a combi- 
nation of signs. 

In the next place it will be of some help in comprehending the 
reason for these combinations of signs to think of conditions within 
the chest as simple problems in physics. That they are not 
always simple does not lessen the value of this conception. The 
normal lung tissue is relatively a poor sound conductor, because 
the alveolar walls reflect and absorb the waves ; the air column in a 
bronchus is a good sound conductor. Fluid conducts sound better 
than air; consolidated lung better than normal lung. From these 
few considerations it is evident that the tactile fremitus will be 
better felt over areas of consolidated lung. Also when a cavity 
communicating with a bronchus is near the costal wall, the fremi- 
tus will be increased over it. And if a collection of fluid in the 
pleural cavity compresses the lung down on a bronchus (fluid 
atelectatic lung, bronchial air column being the interposed media) 
there may be increased fremitus even over the area of effusion. 
On the other hand, if a bronchus be plugged with exudate the 
vibrations of the air column meet an obstacle which may absorb 
them. Or if there be a thick fibrinous exudate over the pleura 
this will also act as a "dampener" for vibrations, and under these 
conditions the tactile fremitus may be diminished or absent. This 
same method of reasoning is applicable to changes in the sounds 
heard by auscultation. If a better conducting medium be inter- 
posed between a bronchus and the area under the bell of the stetho- 
scope then the sounds heard will resemble those in the bronchus. 
Solidified lung is a better conducting medium for sound than 
normal lung, and the emphysematous lung not so good as the 
normal. Therefore loud, bronchial breathing is usually to be 
heard over solidified lung, whereas distant, soft breath sounds 
are the result of emphysema. In the same way, pectoriloquy 

System examination 63 

(exceptionally well transmitted whispered or spoken voice sounds) 
can be heard over solid lung tissue. 

The grosser changes of the percussion note demand no expla- 
nation if only relative densities be kept in mind. A duller note 
means in general a denser medium. From flat or dull over rela- 
tively dense media (solid, liquid) the percussion note changes to 
resonance as the medium becomes less dense and more air con- 
taining. And again there is a gradation from normal resonance to 
the (hyperresonant) note over cavity or pneumothorax, where a 
relatively thin wall of tissue encloses a vibrating volume of air. 
This brief outline is no attempt to be either concise or complete. 
The reason for many signs is not known, and refinements can not 
be imparted by description. They can be learned only by practice 
and demonstration. And there are many variables in tissue 
reactions in morbid states which alter the character of signs. At 
autopsy it is often observed that an area of lung adjacent to 
pneumonic consolidation is emphysematous, and during life the 
fact is notable as an area of increased resonance bordering on the 
area of impaired resonances. Collections of fluid in the pleural 
cavity may produce the same tissue change. On the other hand a 
pneumonic process may occlude the bronchi which lead to the 
bordering area of uninvolved lung. The alveoli supplied by the 
plugged bronchi become atelectatic which is reflected in signs of 
increased density; the pneumonic area then appears larger than it 
is because of the surrounding atelectatic tissue. Failure to recog- 
nize variability in tissue reactions leads to misinterpretation of 
physical signs. An interlobar empyema may produce perfect signs 
of cavity in the upper lobe. In medicine nothing is invariable. 


The criteria for establishing the diagnosis are (a) evidence of an 
infection, usually of rapid onset, (b) symptoms suggesting disease 


of the respiratory tract (cough, blood in the sputum, pain in the 
chest, dyspnea) , (c) physical signs indicating consolidation of lung 
tissue. Of errors in diagnosis the most frequent is failure to 
recognize pneumonia when it is present. This error of omission is 
most apt to occur when pneumonia complicates a chronic disease. 
In nephritis, diabetes, cancer and tuberculosis, pneumonia is 
the usual terminal infection. Pneumonia escapes recognition 
occasionally when the symptoms and signs are suggestive of 
cerebral or abdominal infection. In children pneumonia may 
resemble meningitis or peritonitis. These errors of omission 
may be largely prevented by recognition of their possibility and 
giving care to the pulmonary examination. 

Tuberculous pneumonia may lead to a mistake in diagnosis. 
The onset may be sudden and in other features resemble a pneu- 
mococcus infection. In fact it is a pneumonia. Tuberculous 
pneumonia is to be suspected when the febrile period is unduly 
prolonged and resolution does not occur. The diagnosis can be 
confirmed only by the presence of tubercle bacilli in the sputum. 

In children frequently, and occasionally in adults fluid in the 
pleural cavity gives rise to signs identical with those of consolida- 
tion (increased fremitus, dull percussion note, bronchial breath- 
ing, whispered pectoriloquy). Sometimes a change in the posi- 
tion of the heart gives a clue, and often the exploratory needle is 
required to clear up the question. When there is any suspicion of 
empyema exploratory puncture should be done at once. In some 
types of infection empyema may develop with amazing rapidity. 
I have observed a number of cases requiring the aspiration of 
several hundred cubic centimeters of pus within twelve hours after 
the first symptoms of sickness. The rapid development of 
empyema is notable especially with the streptococcus pneumonia 
of measles, with acute interstitial pneumonia and the pneumonia 
of influenza. While the physical signs may in these cases indicate 


fluid, the mere rapidity of development is conducive to their inter- 
pretation as atypical signs of consolidation. 

No hard and fast differentiation by physical signs can be laid 
down between lobar pneumonia and broncho-pneumonia. In the 
majority of cases the consolidation of a lobe or part of one lung in 
lobar pneumonia contrasted with the smaller discrete areas through- 
out both lungs in broncho-pneumonia is sufficient for diagnosis. 
But in young children, and occasionally in adults, the small areas 
of lobular consolidation coalesce until a whole lobe is involved. 
The signs then may be identical with lobar pneumonia. This 
condition is more apt to take place with primary broncho-pneu- 
monia of young children and is mistaken for lobar pneumonia 
which is exceptional in the first two years of life. Broncho- 
pneumonia is frequently overlooked because the areas of involve- 
ment may be small, scattered, and migratory, and the patient 
does not always seem very ill. Every case with signs of bronchitis 
following a "cold" should be watched for signs of consolidation. 
Transitory shadows of consolidation may be revealed by fluoro- 
scopy when definite signs of consolidation are absent. Broncho- 
pneumonia and pulmonary tuberculosis are easily confused and 
this is especially true of the post-febrile pneumonia in children. 
When sputum is not available for examination only time and 
circumstances can decide the question. 

There is no laboratory test by means of which the diagnosis of 
pneumonia can be proved. The appearance of the sputum is a 
supporting sign but diplococcus pneumoniae may be found in 
normal sputum. Increase in the leukocytes of the blood helps only 
when some disease like typhoid is in question. The urine should 
be watched, first to determine whether the patient is drinking 
enough water and second for signs of complicating nephritis. 

In pneumonia examination of the chest is necessary from time 
to time during the course of the disease in order to detect exten- 


sions of the involved areas and possible complications. These 
examinations should be made no more frequently than necessary 
as they are fatiguing to the patient. Once daily is usually ample. 
Just as important as the pulmonary signs is the condition of the 
heart. Pericarditis is often a complication. And there is never 
an excuse for neglect of the abdomen and failure to recognize a 
distended bladder. Important complications to be watched for 
are empyema, meningitis, and, in children especially, otitis 

Pneumonia Sequelae. — Delayed resolution is not uncommon 
and is recognizable only by the persistence of signs of consolidation. 

Abscess of the lung may be suspected on account of the 
protracted course of the pneumonia, the character of the sputum 
and the type of temperature curve. In addition to the physical 
signs of cavity detectable perhaps only after a paroxysm of cough- 
ing, radiographs are of great assistance. Sometimes by changing 
the posture of the patient during fluoroscopy the line of the surface 
of the pus in the abscess cavity may be seen to move. The 
fetid character of the sputum may give the first clue in both 
abscess and gangrene. 


Seldom, if ever, will the facts revealed by physical examina- 
tion of the chest alone justify the diagnosis of tuberculosis. 
Diagnosis is established by demonstrating tubercle bacilli in the 
sputum. This demonstration may be either of numerous bacilli 
on one examination or of rinding repeatedly small numbers of 
organisms. "In many advanced non- tuberculous pulmonary 
diseases the chief, if not the only point of differentiation, is the 
absence of tubercle bacilli in the sputum" (Lawrason Brown). A 
diagnosis built up on other data is inferential and based on prob- 
ability, and while usually correct is always subject to error. In 


tuberculous pneumonia and general miliary tuberculosis the 
history of the patient, and especially the character of any recent 
sickness is important. The pathologic changes in the lungs may 
be simulated, in so far as detectable by signs, by a number of 
different diseases of which syphilis of the bronchi and mycelial 
infections are examples. The characteristic lesion of tuberculosis 
is the tubercle which is always surrounded by an area of inflamma- 
tory reaction; tubercles tend to coalesce into masses producing 
areas of consolidation which become necrotic ; caseation, and finally 
a cavity results. This series of lesions manifests itself in physical 
signs first as a localized bronchitis, later as an area of consolida- 
tion, and still later as a cavity. Healing of the lesion by its 
inclusion in scar tissue may occur at any stage of the disease or 
may occur in one area while another area is progressive. Conse- 
quently the possible signs in any individual case are numerous 
but simple to understand if the basal pathology be kept in mind. 
From an anatomical point of view pulmonary tuberculosis is 
subdivided according to the degree of progress of the lesion; 
miliary, caseous, ulcerative, fibroid. From a clinical point of 
view the most important question is whether the lesion is progres- 
sive and active, or quiescent, inactive. This question of prime 
importance to the patient is decided not only by signs in the lungs 
but by general conditions reflecting the patient's health: body 
temperature, weight curve, strength and endurance, and so on. 
There are then two questions presented by every case of suspected 
tuberculosis (i) is a tuberculous lesion present,* (2) is the lesion 
active? Sometimes the first question is decided by the second, 
as in early and acute types of the disease, rales are the most 
important single sign. The symptoms in general of tuberculosis 

* To some extent this statement is academic since very few individuals, prob- 
ably, escape tuberculous infection. Those who have never had clinical symptoms 
carry lesions usually too small to give any sign. 


are those of a chronic infection, but some symptoms are due more 
commonly to tuberculosis than to other infections. In the absence 
of other known cause tuberculosis is suggested by such symptoms 
as fever, loss of weight, lack of endurance, lassitude, " neurasthe- 
nia," digestive disorders, cough, morning expectoration, after- 
noon chills and night sweats. The first symptom may be 
haemoptysis (which may occur also in aneurysm, mitral stenosis, 
bronchiectasis and syphilis of the bronchi). Besides a history of 
exposure to tuberculosis or some occupation that predisposes to 
pulmonary disease (i.e. brass polishing), a history of pleurisy with 
effusion is of most moment. "Idiopathic" pleural effusions are 
usually tuberculous (over 80 per cent.). 

The most important sign in the lungs to be detected by physi- 
cal examination is the persistence of rales, heard on repeated 
examinations and localized in the upper lobes. Localized and 
persistent rales indicate a localized inflammation (congestion, 
oedema). They may be heard at the end of inspiration or only 
in the inspiration following cough. In suspected cases it is 
necessary to search for rales repeatedly at intervals of a few days, 
in order to detect or confirm their presence. During the period 
of observation a record of the patient's temperature should be 
kept. A daily rise of over one degree is in any person a matter 
requiring investigation. Subnormal temperatures indicate a low 
vitality. If there be any sputum a careful search for tubercle 
bacilli is requisite. Daily examinations are unnecessary and are 
conducive to carelessness in examinations. One thorough search 
is more valuable than a number done as part of a hasty routine. 
When tubercle bacilli are not found, radiographs of the lungs are 
needed. Localized cloudiness in the picture which is produced by 
parenchymatous changes in the lung is to be looked for. 

The other physical signs which occur in the lungs in tuber- 
culosis are more indicative of the extent of the lesion and the degree 


of progress of the disease. A slight impairment of the percussion 
note over the diseased apex occurring with early "infiltration" 
is common, and when the area is large and caseation present 
there are clear signs of it in dulness and usually a bronchial 
quality to the breath sounds. The breath sounds, however, 
may be various, depending as they do not only on the patency 
of the bronchioles and the density of the involved area, but also on 
the thickness of the overlying pleura. All gradations of percussion 
note and breath sounds are possible and only the sum total of 
signs is significant. A cavity surrounded by a fibrous wall, and 
that in turn by partly infiltrated tissue, may give rise to dulness 
with a tympanitic quality; and bronchial, amphoric, or harsh 
vesicular breath sounds depending on the size of the cavity, its 
relation to a bronchus and to the chest wall. 

In summary, then, a patient who has no known cause for lack 
of endurance, loss of weight, fever, rapid pulse and night sweats 
should be suspected of a tuberculous infection. In order to make 
a provisional diagnosis of pulmonary tuberculosis there should 
be one or both of the following facts (1) persistence of moderately 
coarse rales in the upper chest, (2) shadows in the radiograph of 
parenchymatous changes in the lungs. If there be a history of 
hemoptysis or of pleurisy with effusion the diagnosis is highly prob- 
able. The diagnosis is assured only by finding tubercle bacilli in 
the sputum. 

So many factors enter into consideration that the complement 
fixation test in suspected tuberculosis is not yet a practical clini- 
cal method. 

The conditions which are most often mistaken for tuberculosis 
are (i) delayed pneumonic consolidation, (2) bronchiectatic 
cavities, (3) syphilis of the bronchi, and (4) fungoid infections. 
Any one of these may produce constitutional symptoms and 
physical signs closely resembling pulmonary tuberculosis. 


Neoplasms, primary in the lungs, are rare and are not infre- 
quently mistaken for tuberculosis. Paroxysmal dyspnoea and 
pain in the chest, the usual early symptoms of neoplasm, are 
not ordinarily the first symptoms of pulmonary tuberculosis. 
Since the new growth involves and often occludes a bronchus 
there is dulness or even flatness on percussion with diminished 
or absent fremitus and breath sounds. In brief, the signs are 
anomalous and should excite suspicion. There may be pleural 
effusion, especially when the pleura is involved, which masks 
the primary disease. The fluid is hemorrhagic in only a minority 
of the cases on record. The striking feature when the pleura 
is implicated is the rapidity with which the pleural exudate 
forms, requiring frequent aspiration for the relief of dyspnoea. 
One of my cases which was reported by Habliston required aspira- 
tion over thirty times in two months and a total of thirty- two liters 
of fluid was withdrawn. 

Metastatic growths in the lungs are not uncommon. They 
are to be looked for when pulmonary symptoms arise in car- 
cinoma of the breast, hypernephroma and sarcoma of the bone. 

It is always difficult, and sometimes impossible, to exclude 
the possibility of tuberculosis. Under two years of age the tuber- 
culin test is negative in healthy children. Healthy adults may 
react positively. When fever is absent the subcutaneous tuber- 
culin test may be used; the absence of a febrile reaction to 10 
mg. of tuberculin renders tuberculosis an improbable diagnosis 
but does not absolutely exclude it. 


The examination of the pleura in practice is inseparable 
from examination of the lungs, but is often neglected when 
no pulmonary affection is suspected. Fibrinous pleurisy, detect- 
able clinically by tactile and audible friction, occurs not only 


secondary to pulmonary infections like pneumonia, but is also a 
common complication of rheumatic fever, chronic cardiac and 
renal disease. Pleuritic adhesions are found at autopsy in cases 
of chronic nephritis. The only difficulty presented in the recog- 
nition of fibrinous pleurisy is in the differentiation of friction 
sounds over the left precordium. Pleuro-pericardial friction is 
sometimes very difficult to distinguish from the rub of pericarditis. 
Pericarditis is apt to extend to the base of the heart and the 
rub is not influenced by respiration. But a pleuro-pericardial 
rub may be produced by the heart's movement and little changed 
by holding the breath. At times decision is impossible. 

The pleural cavity may contain fluid under two primary 
conditions (i) as a result of pleural inflammation (exudate), (2) 
as a sequel to passive congestion., transudate. The physical 
signs in these are identical when the exudate is free and not 
circumscribed by adhesions and differentiation then rests on eti- 
ological factors and the character of the fluid. Since exudations 
are a consequence of inflammatory reactions in the pleura they 
are often circumscribed by adhesions between the pleural mem- 
branes. Encapsulated or encysted effusions may occur anywhere 
within the pleural sac or between the lobes of the lung. Encap- 
sulated exudates most frequently follow pneumonia. Empyema 
is often encapsulated. The physical signs over fluid are variable 
to an extreme, and there is no combination of them which invari- 
ably indicates fluid. Even the displacement of the heart which 
takes place when the amount of fluid in the pleural cavity is con- 
siderable, may occur also as a result of a voluminous pneumonic 
consolidation. This fact can be verified in the autopsy room 
in cases where one whole lung is consolidated. 

When there is a considerable effusion in the pleural cavity 
inspection will reveal probably that the patient is dyspneic, 
perhaps cyanosed, and that one side of the chest moves less than 


the other. The affected side may also look fuller. And possibly 
the apex impulse can be seen in an abnormal position. These 
impressions are confirmable by palpation; and. also by the fact 
that vocal fremitus is absent over the lower immobile chest. The 
percussion note is flat and boardy indicating a marked increase in 
density of the medium. The breath sounds are feebly heard, per- 
haps vesicular, perhaps faintly tubular, the voice sounds distant 
and with a peculiar nasal quality (aegophony). Above the area 
of dulness, in front, the percussion note is especially resonant 
(Skodaic), even tympanitic, and here the breath sounds are 
abnormally clear, sometimes even amphoric. Changing the pos- 
ture of the patient may in rare cases effect a change in the area of 
dulness (shifting dulness). The heart sounds can be heard best 
in an area indicating that the heart is pushed away from the 
affected side. An area of impaired resonance may be detectable 
along the spine on the side opposite to the effusion, triangular in 
shape and 3 or 4 cm. wide at the base with apex upward 
(Grocco's sign). These are the socalled "typical signs" of large 
effusions. Only a minority of cases present " typical signs." 

Smaller amounts of fluid in the pleural cavity are frequently 
overlooked or mistaken for areas of consolidated lung. This mis- 
take is most frequently made when the fluid is encapsulated or 
encysted between the lobes. The chief reason for error lies in 
the idea that only a certain definite combination of signs can be 
produced by effusion. This is incorrect. Fluid can produce signs 
very similar to, if not identical with those of consolidation or 
cavity. The presence of bronchophony, even pectoriloquy, does 
not exclude fluid, and the pseudo-cavernous signs associated with 
encysted effusions particularly in the upper parts of the chest are 
not rarely found. Bronchial breathing over fluid is usual in 
children and it is not infrequent in adults. Nor does the 
presence of rales exclude the possibility of underlying fluid. 



What is the explanation of these atypical signs? In large 
effusions the area just above the fluid is more resonant to percus- 
sion than normal, often even tympanitic (Skodaic resonance) and 
the breath sounds are exaggerated, or bronchial with sometimes a 
definite amphoric quality. Now in empyema encapsulated 
between the upper and lower lobes for example, the lappet of 
lung between the fluid and the chest wall simulates the area just 
above fluid, the area where Skodaic resonance, etc., are notable. 
The signs then will depend largely on the thickness of this inter- 


Fig. 17.— Interlobar empyema, schematic, from autopsy. A, Area of Skodaic 
resonance; B, site of exploratory puncture. 

vening area of lung tissue and also, of course, on whether resolution 
in the lobe is complete or not. The recognition of signs indicating 
the possibility of small amounts of fluid in the pleural cavity is 
most important because empyema is the most common complica- 
tion of pneumonia. The meaning of signs is often equivocal and 
whenever empyema is a possibility the question must be decided 
by the exploratory needle. Delay is more dangerous than thora- 
centesis. When there are signs indicating the presence of fluid a 
radiograph may be of assistance, but they are often misleading 
and never supplant the information secured by exploratory 


puncture. Very often the empyema sac is surrounded by partly 
consolidated lung or consolidation that has not completely resolved 
and the shadow of this entirely obscures the fluid. The intelli- 
gent interne is prone to have radiographs made at once when he 
has demonstrated an effusion by puncture, and from the absence 
of perfect accord of the radiograph with facts, he learns the limi- 
tation of all methods. This is clinical wisdom. 

Fluid obtained from the pleural cavity by puncture should be 
examined for the type of cells and bacteria present. A stained 
smear will help to decide whether empyema is streptococcic or 
pneumonococcic, the immediate question, since treatment of the 
two differs — a differential count of cells from a centrifugalized 
specimen when the liquid is not pus, should be made — when 
lymphocytes predominate this fact suggests tuberculous pleurisy. 


Air may enter the pleural cavity through punctured wounds of 
the chest wall (stab-wounds) or through openings made by breaking 
down of lung tissue. Perforations of the lung result from local 
disease (tuberculous caseation or cavity, 90 per cent), pleuro- 
bronchial fistula following empyema, abscess, etc. Occasionally 
the pleura is perforated through the diaphragm or oesophagus 
usually by neoplasm of the stomach, colon or oesophagus. The 
physical signs of pneumothorax are influenced first by the amount 
of air in the pleural cavity which determines the degree of collapse 
of the lung, and second by the presence or absence of fluid. Since 
the majority of cases of pneumothorax result from tuberculous 
lesions in the lung, pleurisy with effusion usually accompanies the 
pneumothorax. When the negative pressure in the pleural 
cavity is completely relieved and the lung is collapsed around the 
hilus, motion of the affected side is abolished and in thin subjects 
the intercostal spaces disappear. The heart is usually displaced 


unless held by adhesions. Vocal fremitus is usually diminished, 
sometimes absent and this with a hyperresonant or tympanitic 
percussion note should excite attention. All gradations of percus- 
sion note may occur, depending on the volume of air present and 
its tension and the amount of fluid. Usually the note is tympa- 
nitic in some degree, occasionally amphoric or a dull tympany 
(Skoda's resonance). But in rare cases the note is muffled; almost 
dull. This is apt to occur when the pneumothorax is followed by 
considerable effusion which causes the air to be under tension — a 
true positive pressure. When fluid is present there is the 
customary dulness at the base which can be made to shift by 
changing the posture of the patient. The breath sounds ordi- 
narily are poorly heard, sometimes entirely suppressed, again 
distant with a faintly amphoric quality to the inspiratory sound. 
The voice is distant and nasal. Possibly the lung tissue matted 
about the bronchi absorbs the breath and voice sounds. When 
rales are present they have a peculiar "metallic tinkling " 
(Laennec), a sort of echo. The most important special test is 
the Hippocratic succussion which is elicited when the examiner 
places his ear to the affected chest and shakes the body of the 
patient. A characteristic splash is audible. There is no succus- 
sion unless both air and fluid be present. The coin sound (bruit 
d'airain of Trusseau) is also usually obtainable when the examiner 
listens at the back while an assistant taps one coin against another 
held to the front of the chest. A radiogram may be very helpful 
in the diagnosis of doubtful cases. The fluid is usually freely 
movable in pneumothorax, and this fact can be demonstrated in 
the plate and by fluoroscopy, by changing the patient's posture. 
The presence of air in the pleural cavity can be demonstrated by 
exploratory puncture and interposing a bottle rilled with sterile 
water between the needle and the syringe. 

Three errors in diagnosis are possible, simple pleural effusion, 
diaphragmatic hernia, and a very large cavity in the lung. 


Diseases of the heart and vessels are the chief cause of death in 
this country, surpassing both pneumonia and tuberculosis.* 

The responsibility for their recognition and treatment, there- 
fore, can hardly be escaped. Yet it is safe to state that no class of 
human disorders is more often mistaken in diagnosis than those of 
the circulatory system. In respect to the heart the chief cause 
of error lies in two fundamental misconceptions (i) that a cardiac 
murmur always indicates heart disease, (2) that a heart is neces- 
sarily sound when no murmur is present. There are exocardiac 
murmurs of no clinical significance, and portentous manifestations 
of cardiac disease with no tell-tale murmur. A murmur is not a 
pathognomonic sign. Very seldom, if ever, can diagnosis rest on 
this sign alone. The effects of cardiac disease may appear only in 
symptoms as in some cases of angina pectoris; or in the character 
of the rhythm alone in early myocardial degeneration; or in signs 
suggestive of adherent pericardium supported by an etiological 
factor for pericarditis (e.g. rheumatic fever). Again in signs 
alone, without symptoms; for example a large heart with a dias- 
tolic murmur in the aortic region, and a Corrigan pulse indicates 
aortic insufficiency. In some cases the decision of a question as to 
whether certain signs indicate organic disease or not, depends on 
whether or not there has been an etiological agent for such disease. 
In examination then the physical signs of particular significance 
are, (a) the character of the pulse, (b) the size of the heart, (c) the 

* Of 1,068,932 total deaths in 1917, 115,337 were due to heart disease, 62,431 
to apoplexy and 19,055 to arterial disease, a total of 196,823 due to circulatory dis- 
eases, against 112,821 for pneumonia, and 110,285 for tuberculosis. 



character of its sounds and murmurs. These signs mutually 
check and corroborate each other. 

The Pulse. — Some pulses always betoken cardiac disease, 
auricular fibrillation and pulsus alternans for example, and these 
are examples of disorders of rhythm. Rate alone is not so apt to 
be decisive. An acceleration of rate while usual in various sorts 
of cardiac incompetency (because it is in a sense, a compensating 
effort) , may also be due to numerous influences, mere apprehension 
for example. Constant tachycardia suggests either disease of the 
heart, nervous system or an intoxication. The only objective 
evidence of paroxysmal tachycardia may be the sudden accelera- 
tion of the pulse rate to 180 or over, and its subsidence just as 

Slowing of the pulse well below the average rate occurs 
physiologically in the puerperium but rarely in normal persons. 
Bradycardia is also often notable during convalescence from fevers, 
with jaundice, in poisoning by alcohol, tobacco and digitalis, and 
occasionally in fatty and fibroid degenerations of the myocardium. 
When the pulse falls to 40 per minute or below, this fact suggests 
a delay in the passage of the contraction impulse from the auricles 
to ventricles (delayed conduction), the most marked degree of 
which is found in heart block. In heart block the pulse is usually 
below 40. The auricles may beat several times to each ventricular 
contraction and the auricular contractions may then be audible 
with the stethoscope and are demonstrable in polygraph or electro- 
cardiograph tracings. Heart-block is a conspicuous sign in 
Stokes-Adams disease. 

Irregularity of the pulse may take two forms, irregularity in 
rhythm and irregularity in force. The commonest arrhythmia 
is the acceleration of the pulse rate during inspiration, and its 
fall during expiration. This is normal in young individuals. 
Allied irregularities during early life are grouped with it under 

7 8 


the term "sinus arrhythmia" and are due to nervous influences. 
These arrhythmias are not pathological though many a healthy 
child has been doomed to vegetate because of a mistaken notion 
of their portent. Sinus arrhythmia can be recognized as a rule 
either by the relation the arrhythmia bears to respiration or by its 
disappearance after exercise. 


Fig. i 8. — A normal electrocardiogram. The waves marked P are due to the 
beginning of auricular activity. The group of waves which are marked Q, R and S 
are due to the beginning of ventricular activity. The wave marked T is due to 
the latter part of ventricular activity. 

The pulse may appear to skip a beat, at intervals, producing 
an impression of intermittency. When "dropped beats" occur 
regularly after every second or third beat there results the bige- 
minal or trigeminal pulse. This arrhythmia, due ordinarily 
to extra or premature systoles, may be an anomaly and persist 
through life. Sometimes it occurs temporarily after debilitating 
diseases. Associated with palpitation it may result from excessive 
use of tobacco, tea or coffee, and disappear when the patient 
becomes more temperate. Or in organic disease of the heart 



muscle premature systoles may be one of the signs. It is not 
difficult ordinarily to recognize arrhythmias due to premature 
systoles. The impression received by the palpating finger is 
that the pulse is regular with now and then an extra beat and 
an intermission, hence the name " regular irregularity." Even 
when the premature systoles are fairly numerous this impression 

- -ft ~£ ' r> rr3 

, ft-4- -—fr-t- T - k '!•■ 



;■ ;: . jl_ 

— ■ — — -a-- — - — : ---i 

*_ -_ 

< j i - I 

L"'! r 

"; " ■ - " : - ',;■ - """ "f5 '['•'. " : ' ;• 


l W"*^wij^wgft»- W 1 ! 

Fig. 19. — These records illustrate ventricular predominance. That on the left 
indicates left ventricular predominance by the small R and deep S wave in lead 3 
while the R wave of lead 1 is upward. 

The record on the right indicates right ventricular predominance by the fact that 
£ is much larger than R in lead 1 and R in lead 3 is well developed. This record also 
indicates auricular hypertrophy by the fact that the P waves are wide and notched 
and by the large size of P in lead 2. 

of regularity persists.* Occasionally premature systoles are so 
numerous that it becomes difficult or impossible without a tracing 

* Premature contractions may be either of auricular or ventricular origin, more 
often the latter, and the compensatory pause or intermission is then easily recog- 
nizable. Auricular premature contractions may not be distinguishable without 
graphic records. Rarely premature contractions originate in the auriculo-ven- 
tricular junction. Every student should know Thomas Lewis' Clinical Disorders 
of the Heart Beat. 



to distinguish this arrhythmia from auricular fibrillation. In 
the irregularity of premature contractions the impression received 
is that the intervals between beats is in general regular and equal. 
In auricular fibrillation the impression is of complete irregularity. 



?■ ft 



i »\ 





Fig. 2o.-^This record shows auricular premature beats in leads 2 and 3 at the 
points indicated by arrow. The P waves of these premature beats have a different 
shape from the normal P waves of this record and are also too early in their appear- 
ance. They originate from hyperirritable foci in the auricles and are followed by 
ventricular contractions of the usual sort. 

There are no equal intervals. The pulse seems entirely disordered 
and haphazard. Not only is there inequality in the intervals 
between pulses but the size of individual beats varies, and exami- 



nation of the heart with the stethoscope reveals irregularity 
in the strength of contractions as indicated by the quality of the 
first sounds. Auricular fibrillation always indicates serious 

m\. t ; Jt L '■ 
0\ %f*f*$g^ jP*l i#t#1 

I ' : f " 
i 1 — 

.Fvki i 
i ' ftp " 

- ■ 1 ■ • w 
! ^ 


\k : 


\i ! 


'x! . . ! 

rf-'fi-T PPM ■!• 1 

; : I ; : \ :j ; • 

? ' 







-*£. ! 

Fig. 21. — This record illustrates ventricular premature beats in all three leads, 
at the point marked X. These peculiarly shaped waves, besides being premature 
are very different in their form from the ordinary ventricular contractions in this 
patient. These contractions originate in a hyperirritable focus in the right ventricle. 
We localize them to the right ventricle because S is longer than R in lead i and R 
is tall in lead 3. 

myocardial disorder, and is frequently seen in cardiac decom- 
pensation. When there is a marked variation in the force of 



the ventricular contractions, some contractions will be too weak 
to produce a radial pulse. The rate per minute at the wrist 
is less than the contractions heard at the apex. This is desig- 
nated a "pulse deficit" and means a laboring heart. 

\ lsi_i Lite . 

j ' T 

f~~ :T i7 r f 

J- . | " 


..^._. ? . 

■>■ ■:•■-:■ ;^ 

•'- ■ ' ■ i ■ < ' ■ i i ■■ ■- 

!! — 

. ..... | ... ^1. | . . , . j . . , ^ 





. r • J • p j 

T ' 



i ! ' : i 'j 

j I" " " j * r • | ' 

Ppl^l M S 1 • 1 : i '.' 

J .._ ; ; ] 

" f" i*--:~ 'j--' :-:-.; [::••: :'j: 


. : 1: 


................ .; 


. 1 | . . : 1 , I 1 . i 



. £" ii*." j 

:::•£: :Q : ":.jLt i LLiil. :.:":; 

! — :.ii 



' l <mml #&m 


e_ y | 

, _ ]T; t] . -/7|t rl 

. j.s 



fMn'fi "" 


■ ' i t 

i ■ i j * . i 

..-.. j • • : } j : : J . . 1 ii 

f : 
i: : j 

ill : .!.. --J.-. . 1. . . 


: " { 

1 } | j [• | I 

. 'j 

• • 1 ! : ^ 

|:.Ll. Li.:..: .-1 : J': . . f: . 1.... 


[ j : 

:..]'• : 

■ i 1 ' ■ I i : 
-j.:. j-; :: N::;j 


' ! 1 

: . .(.... 

. . . i . . . . 

j . j . . 1 . - j 

- - ; 










n j '£i 

■ - } 
' ' ".1 ,;• "" 



- ; 

. . " : d 



..:..;.,.: }-:■-• j : - ■-{--• ■•[ 
I . j 1 j ; 

||f | - r "j \ r '\ 


1 |s • t- - | ■ ■ ° 

j .!..• LillJLu 1 ..:_L :J. J 

R T-l 

'" r's 

: .. :.;.) :.:.:. 

■lirit: ":~: 



: if 

Fig. 22. — This record indicates auricular fibrillation by the absence of normal 
P waves and the presence of the little wavelets marked ff which are seen in all 
three leads. Note how they vary in shape and size throughout the record in marked 
contrast to the waves of auricular flutter. 

The vast majority of arrhythmias are easily recognized by 
the skilled clinician without recourse to pulse tracings or records 



but some disorders are detectable only through a study of graphic 
records. The best of these, because it discloses not only rhythm 
but myocardial states, is the electrocardiograph, but much can 
be learned from a short record of the pulse made with the small 

T; J" j "" 

- 1 - I ! - 


ill I :.:} : 

' Ft J 

:'- j: T$ \ 

J ' ■ ' 

' j ■ 

::'".{:: ; 

'• -i it 

id Wi 

.. 1 M : 


. 1 .11 

\p.\ . 

P I • 

. *""•" 7 -" " ' ; 

T '';:{: :TJT ''HT ' 


:p:.-- :i . 

..., }.-•!... T. J :: i ...j : L.:... : I ,:~:..:.l:.^~i 

'. - ' '. 1' ' ' ' \ . ' ' l\ 

;i' T; 

:....). . . . j .: : . 

J j | ! 1 T . : : : J : : : : j ::. : : 

.. . \ j |. .11: ..\ . ..I . Li: : :: J..::.:;.. 

:*■{:: :{:,::] 


; '; : t' * ' | • ■ ■ 

B" - : i • L- ! I 1 J ~s4 • ■ 



rrrrjr hrrrnfr-rh rrl 1 j--— |--f Frrrfr— 


... Ir - : :I;T :[" ' :) „ '}•■'" ' t. ■ ■ ' ' 1 ' : ' ' ' T . 

[Hit];:! IT:: IT 

L . ... ..... 

m :;.! !...:! ... 

! L ! i is •! 

f : '1 T! 



t :|- . 1 .! ill; ,:l .'. ! .:■-'.. Ls 

|_ .|... 4-^tj 

; T ■ ; • 'I :: ' ' 

"); j'TT i -|-j • : ' 1 ■ • j : "T • ■ ' ' i ' ] • ; T : : ; ' 

• 1 ■ j • ■ ;"• ; 1 1; , _ i j : j ' l-4~ ' ] ' ' 

iTFTf:: Li }:■:•:- -!:!• f I- j 
[Ij-U-::: :g! ;::: T:i :::: :: d::: I j .. j; _.j . j _ 

1- l ' 

j/Vl ■ /\ ■ "fV- ■ f [i| T 

1 At* :] 

b J J/UJ 

~ ;r TaF t ;r T ::: l ^ijf \'l" : i 

lj/ \ ; 




L' 1 

?' ; '] i 

1 "1 : Y ! 
- ■ ' jj ; • j 

^.TTq_ : .jTTj 5r '[...; 

I T|. UrJ:: j Jj ; | | . 
j 1 1 L J J ' * 

: 1 • j I 

J j. j. . j| 

s Jj 

Fig. 23. — This record illustrates abnormalities which are due to myocardial 
disease. (1) The notching of S in lead 3 and R in lead 1 indicated by the arrows; 
(2) the T wave in lead 1 is turned downward instead of upward. 

Dudgeon recorder. Pulsus alternans is exceedingly difficult to 
recognize without graphic records and yet it is important since it 
betokens grave myocardial disease. As the alternation in the 
pulse is a result of alternating force of ventricular contraction 
the disorder can sometimes be recognized while taking the blood 



pressure. If it is found that at some pressure below the 
systolic, only alternate cardiac systoles are audible below the cuff 
of the sphygmomanometer, pulsus alternans may be suspected. 

The difference between the systolic pressure and diastolic 
pressure in an artery is called the pulse pressure. The pulse 
pressure varies in different diseases. An elevation of the systolic 
alone, the diastolic remaining normal, increases the pulse pressure. 

Fig. 24. — Two records which illustrate the effect of rather severe myocardial 
disease. These are the waves due to bundle branch block with the wide notched 
QRS group and the T waves opposite to the QRS in leads 1 and 3. The direction 
of the waves of the QRS group in leads 1 and 3 indicate the side of which the bundle 
branch is damaged. That on the left indicates damage to the right bundle branch 
because R is large in lead 1 and S is large in lead 3. That on the right indicates 
damage to the left bundle branch because <5 is large in lead 1 and R in lead 3. 

In aortic insufficiency the diastolic pressure falls and the systolic 
rises producing a high pulse pressure. 

The size of the heart may be the determining factor in diag- 
nosis. Hypertrophy of high degree (cor bovinum) is found 
in copious beer drinkers,* and in aortic insufficiency and adherent 

* In the Pathological Museum in Munich there is a remarkable collection of 
"Beer Hearts," some of amazing size. The employees of the breweries are per- 
mitted to drink ad libitum, and it is said many average ten liters a day! 



pericardium. In extreme cases the heart may weigh 45 ounces. 
Lesser degrees of hypertrophy are common in valvular disease, 
nephritis, goitre and many other disorders. 

The area of precordial dulness is enlarged by cardiac hyper- 
trophy, by dilatation, or by fluid in the pericardial sac* Differ- 

Fig. 25. — A record which illustrates a peculiarity of the T wave often present 
after coronary artery occlusion. The characteristic feature is the upward convexity 
or hump indicated by the arrows which precedes the downward T wave. 

entiation between these conditions depends somewhat on whether 
the extension of the normal cardiac area is to the left or right of 
the sternum and to a very large extent on accessory factors, 

* Moritz tested the method of determining the size of the heart by percussion. 
He compared in a series of cases, the area of cardiac dulness with the shadow of 
an ortho-diagram. The variation was approximately i cm. 



such as a cause for hypertrophy or dilatation (hypertension, 
valvular lesion, etc.); the location of the apex impulse, and its 
character whether forceful or weak. The precordial dulness 
may be shifted or distorted by adhesions which displace the heart 



:.:{. — 

— ~{r 

- - - • 

.: :-J 

:. r . 



: _33 

Fig. 26. — This record has no abnormality except the small size of all the waves. 
This is due to a small production of electricity by the heart (low voltage) and de- 
pends upon a poor functional condition of the muscle allied to fatigue. 

or by mediastinal tumors, and lead to confusion. When the 
hypertrophy is predominantly of the left ventricle the cardiac 
apex is displaced toward the axilla and downward. In aortic 



insufficiency the point of maximum impulse may be in the sixth 
intercostal space and mid-axillary line. Predominant hyper- 
trophy of the right ventricle is difficult to determine from the size 
and shape of the heart alone. The apex impulse is found outside 
its normal location, and is not so apt to be displaced downward. 
The transverse area of dulness is increased. Hypertrophy 

Fig. 27. — Aneurysm. 

in general causes the apex impulse to be less sharply localized 
and the palpating hand detects a more forceful character in the 
impulse which may amount to a " thrust." This impression of a 
forceful impulse disappears when the myocardium has undergone 
degeneration with consequent dilatation of the ventricle. When 
the area of cardiac dulness is enlarged the facts which point to 



hypertrophy are enlargement of the area to the left of the sternum, 
the character and location of the apex impulse, and the presence of 
a disorder which might cause hypertrophy. 

Fig. 28. — The index of cardiac enlargement. The #-ray plate is made with the 

diameter of heart shadow 

patient 6 ft. from the tube. The index is — = normally 

diameter of the chest 

5.6 cm. + 11. 2 cm. 
In the illustrations above - =61 %, marked 

40 - 45 %. 

26.9 cm. 

Enlargements of the heart and its shape are detectable with 
some accuracy by radiograph provided the plate be made with 


the tube six feet from the patient (teleroentgenogram) in order to 
secure parallel rays of light and thus no distortion of the shadow. 
The transverse diameter of the heart normally is about 45 % 
of the chest diameter (see illustration). When the diameter of 
the heart is greater it is regarded as evidence of enlargement, 
either hypertrophy or dilatation. 

Electrocardiograms show preponderance in ventricular con- 
tractions and are of service in deciding which ventricle is pre- 
dominantly hypertrophied. Hence they are useful in deciding 
the question of right ventricular hypertrophy for which signs are 
not reliable. 

Dilatation of the ventricles as a cause of increase in the size of 
the heart is determined more from the nature of the associated 
signs, the symptoms, and knowledge of a cause for dilatation 
than from the mere size or shape of the heart. The symptoms are 
those of embarrassed cardiac function. Even slight degrees of 
dilatation produced by violent exercise in healthy individuals 
result in dyspnoea. Dilatation of the ventricles as a result of 
myocardial disease is accompanied by dilatation of the auricles. 
Dilatation of the right ventricle and auricle cause an extension 
of the area of cardiac dulness to the right of the sternum. The 
associated signs depending on degrees of dilatation and cardiac 
insufficiency are those of passive congestion and engorgement, 
distended and pulsating cervical veins, oedema, .enlarged liver, 
passive congestion of the lungs, and in the severest cases, pulsating 
liver, oedema of the lungs, and hydrothorax. 

In accordance with the general physiological laws of muscle, if 
its nutrition be maintained, the healthy myocardium hypertro- 
phies with increased work. The circulatory affections which most 
conspicuously throw increased work upon the heart muscle are 
hypertension, adherent pericardium and chronic valvular disease. 
When the myocardium becomes diseased because of infections, 


or defective blood supply (atheroma of the coronary arteries), 
or the strain of overwork, then dilatation follows. 

Fluid in the pericardial cavity increases the apparent size of the 
heart and may be notable in an increase of the area of precordial 
dulness. This increase is not invariable since adhesions between 
the pericardium and epicardium in its anterior portion may force 
the fluid posterior to the heart. (See diseases of pericardium.) 

Cardiac Murmurs. — A perfectly sound heart may have a 
murmur. To diagnose a diseased heart by a murmur alone 
without other evidence is hazardous. Diseased hearts usually 
have murmurs, and sound hearts usually have not. By the 
study of hearts at autopsy it has been learned that lesions of the 
valves are apt to be associated with murmurs during life, and that 
certain murmurs result from damage to certain valves. It is 
evident from the appearance of these valves and valve orifices at 
autopsy that in some cases the valves must have been incompetent 
to prevent a retrograde flow of blood and in others that the orifice, 
being narrowed must have been an obstruction to the passage of 
blood. These two lesions are designated respectively valvular 
insufficiency (or simply regurgitation) and stenosis. One other 
important fact has been demonstrated by study of cases at 
autopsy, namely that a murmur occurring at a certain phase in 
the cardiac cycle and indistinguishable from the murmur of a 
valve lesion may be associated not with a lesion of a valve, but of 
the heart muscle, perhaps, or with adherent pericardium or some- 
times even with no detectable abnormality in the heart whatso- 
ever. When at autopsy no lesion is found in the heart valves to 
explain a murmur, a study of the clinical record of the patient 
usually shows that the presence of the murmur was not supported 
by sufficient evidence in associated signs to indicate a valve lesion. 
More than this, autopsy statistics demonstrate in respect to mur- 
murs that the possibility of error in diagnosis with some murmurs 


is greater than with others. In general, diastolic murmurs are 
more reliable diagnostic evidence than systolic murmurs. And the 
murmurs heard in diastole toward the base of the heart are more 
trustworthy evidence of valve lesions than murmurs heard in the 
apical region. 

Since the phases of the cardiac cycle are spoken of in terms of 
ventricular action, systolic murmurs occurring during ventricular 
contraction may be produced, by (i) obstruction (stenosis) to the 
normal blood-flow at the aortic and pulmonary orifices, or (2) 
retrograde flow from the ventricles into the auricles (mitral insuffi- 
ciency, tricuspid insufficiency) . During ventricular diastole a 
murmur may be produced by (1) obstruction to the flow from the 
auricles into the ventricles (mitral stenosis, tricuspid stenosis) or, 
(2) retrograde flow from the aorta (aortic insufficiency) or pul- 
monary artery (pulmonary insufficiency). A murmur may not 
fill the whole systolic or diastolic period, but be heard only in a , 
part of it, and then is subject to designation as early or late systolic 
or diastolic. Late diastolic murmurs are usually called presystolic. 
From the physiology of the heart's action graphically represented 
the time of the occurrence of murmur in the several valves is evi- 
dent. The area on the precordium where murmurs are most easily 
heard depends on the direction of the blood flow and the surface 
topography of the valves. 

The auriculo-ventricular orifices are surrounded chiefly by 
muscle tissue, which is affected in any general myocardial disease. 
The competency of the valves partly depends on the tonus of this 
muscular ring, therefore it becomes evident that in myocarditis, 
for example, which results in slight dilatation, this ring of muscle 
enlarges and the valves become incompetent as a consequence. 
This is the commonest cause of a systolic murmur at the apex. It 
is not a valvular disease and therefore, in many cases, the murmur 
disappears when health is restored. Both auriculo-ventricular 


valves are subject to this condition, but the aortic and pulmonic, 
rarely, since their supporting rings are fibrous tissue. 

Many murmurs caused by valvular diseases are influenced 
both in their loudness and in their peculiar quality by the vigor of 
the heart's contractions, i.e., by the state of the myocardium. 

Fig. 29. — Clubbing of the fingers. Congenital heart disease. 

This fact is particularly true of murmurs due to lesions of the 
auriculo-ventricular valves. When the auricles dilate and lose 
their tone the blood is forced through the valve orifice at a slower 
rate and the diastolic murmur becomes soft and distant. Fibrilla- 
tion of the auricles represents the acme of muscular atony, and 


then the most characteristic murmur of mitral disease, the presys- 
tolic rumble, may disappear. In relatively slight lesions of the 
mitral valve the murmur may be indistinct and indefinite but 
after exercise which increases the force of the heart's contractions 
the murmur is clearly audible. 


The most frequent cause of valvular disease is rheumatic 
infection, and the mitral valve the seat of predilection. In frank 
cases of advanced involvement of the mitral valves a definite 
etiological factor for the disease is usually to be found in the past 
history of the patient. The commonest lesion is stenosis and the 

significant sign is a diastolic murmur, which is heard best near 
the apex impulse, and often not heard elsewhere. In any case 
this murmur becomes more distant toward the base of the heart. 
The murmur is first heard near mid-diastole, is soft in the begin- 
ning and grows louder and rougher as it approaches the first 
sound. Often it has a definite crescendo quality in presystole. 
The murmur is apt to end in a sharp slapping first sound which is 
shorter than normal. There is often a presystolic thrill, a pal- 
pable shock at the apex and definite enlargement of the heart 
to the right of the sternum. Right ventricular preponderance 
is demonstrable by means of the electrocardiograph. The es- 
sentials then for diagnosis of mitral stenosis, are etiology, a 
diastolic murmur heard at the apex, and right ventricular hyper- 
trophy. What are the variations ? Mitral stenosis is rarely found 
without mitral insufficiency. Consideration of the anatomical 
aspect of the disease explains this fact. When there is insufficiency 
and stenosis the diastolic murmur may continue into the systolic 
with the merest appreciable interval and the slapping quality of 
the first sound be obscured or lost in the systolic murmur. When 


there is auricular fibrillation the presystolic phase of the diastolic 
murmur disappears, and when the heart rate is rapid no murmur is 
audible in diastole. When the rate is slow a short murmur is 
usually detectable in mid-diastole. Auricular fibrillation per se 
is evidence of organic heart disease and before middle life is 
usually secondary to a mitral lesion. In a patient with a 
rheumatic history auricular fibrillation almost always means 
mitral stenosis. 

Early stenosis of the mitral valve which has never given 
rise to symptoms may present only indistinct and indefinite 
signs. A thrill at the apex, a snapping or slapping quality of the 
first sound or a reduplication of the first sound may excite sus- 
picion, particularly when there is a rheumatic history, and lead to 
more searching examination. The effect of exercise on the 
heart's sounds should be then tested by having the patient hop on 
one foot or run. A characteristic murmur may be audible only 
after exercise. The posture of the patient may influence the 
audible quality of murmurs, and examination should be made 
after exercise with the patient in the erect posture and also lying 
on the left side. 

The condition most often mistaken for mitral stenosis is 
neurovascular asthenia (cardio-vascular asthenia, irritable heart). 
This condition is characterized by subjective sensations of pal- 
pitation, shortness of breath on exertion, ease of fatigue and objec- 
tively by cold, cyanotic hands, rapid heart, often a presystolic 
or systolic thrill at the apex, a short first sound and a short, 
low-pitched hum preceding the first sound. In well defined 
cases where the above signs are pronounced differentiation from 
mitral disease may depend entirely on the absence of an etiological 
factor for valvular disease. Exercise, however, usually decreases 
the signs in these functional cases instead of rendering them more 
pronounced as in organic disease. 



In cases of cardiac decompensation the signs which would 
point especially to mitral disease as the prime disorder are a 
murmur in diastole heard only at the apex region, or a snappy 
first sound at the apex with no definite murmur, or auricular 
fibrillation in a young subject, with hypertrophy of the right 

Fig. 30. — Cardiac dilatation resultant to mitral disease. The right border of the 
heart was 9 cm. from the mid-sternal line as determined by percussion. 

ventricle (determined either by cardiac dulness, radiograph, or 
electrocardiograph) . 

In individuals who have had no symptoms of cardiac disorder 
and in whom no etiological factor for valvular disease is known 
the diagnosis of mitral stenosis requires a murmur in diastole at 
the apex which is supported by other evidence of valve disease. 


Such evidence would be the presence of aortic insufficiency or 
mitral insufficiency together with definite evidence of cardiac 

Three conditions may cause murmurs in diastole audible 
in the apex region and thus lead to mistakes*: adherent peri- 
cardium, the Flint murmur, stenosis of the tricuspid valves. 
In a series of 51 cases presenting diastolic murmurs and definite 
cardiac hypertrophy, autopsy examination showed adherent 
pericardium and no valvular lesion in 24. 

The Flint murmur is presystolic in time, heard in the apical 
region and is associated with aortic insufficiency. It can not 
be differentiated by signs from mitral stenosis. When aortic 
disease is definitely of luetic origin and there is a presystolic 
murmur at the apex a Flint murmur is to be considered. Also 
signs of mitral stenosis suggest a Flint murmur in individuals 
past middle life with aortitis but with no history of rheumatic 
symptoms. When, however, aortic disease is of rheumatic 
origin, a Flint murmur is unlikely on account of the probability of 
both the aortic and the mitral valves having been affected by the 
rheumatic infection. 

Disease of the mitral valves rarely produces insufficiency 
without some degree of stenosis. A systolic murmur at the apex, 
transmitted to the axilla and associated with accentuation of the 
pulmonic second sound indicates mitral regurgitation, but may 
occur without any detectable thickening or abnormality of the 
valve cusps. These signs are frequently found in hypertrophied 
hearts with slight dilatation and also in protracted fevers 
and diseases which lead to low vitality. The accessory signs 
which especially point to an organic mitral insufficiency rather 
than to a myocardial or functional origin for the murmur are (1) 
associated signs of mitral stenosis or of aortic disease and (2) a 
history of rheumatoid disorder. During periods of decompensa- 


tion signs of mitral regurgitation are usual since decompensation 
is a myocardial insufficiency accompanied by cardiac dilatation. 


Disease of the aortic valves results from luetic aortitis, rheuma- 
tic endocarditis and arteriosclerosis. Endocarditis of rheumatic 
origin is prone to involve the mitral as well as the aortic valves 
while the lesion of syphilis is confined to the aorta. Aortic 
insufficiency is ten times more common than stenosis. Insuffi- 
ciency frequently occurs without stenosis, but stenosis without 
insufficiency is rare. 

There are two characteristic signs of aortic insufficiency, a 
murmur heard at the base of the heart in early diastole and a 
collapsing, water-hammer pulse (Corrigan pulse). The murmur 
begins early or directly after the second heart sound and is apt 
to be diminuendo in quality. It may be loud and rough or 
soft and distant. Usually best heard at the left sternal margin 
in the second and third interspace, the murmur may in some cases, 
however, be heard only at the right border of the sternum or even 
over the sternum. Faint distant murmurs are sometimes heard 
better by direct auscultation with the unaided ear than with the 
stethoscope. The most favorable position of the patient during 
auscultation is with the trunk bent forward. Some murmurs are 
heard only after forced expiration. The aortic second sound is 
diminished, sometimes inaudible. 

The collapsing or water-hammer quality of the pulse is not only 
notable at the wrist but is often visible in the carotid, temporal 
and brachial arteries, * and may be palpable in the dorsalis pedis. 
When listening over the femoral arteries with a stethoscope the 

* The character of the pulse is usually visible in the retinal arteries. The 
capillary pulse can be made visible at the base of the nails by pressure on the tip 
sufficient to produce some blanching. 



pulse has a peculiar quality described as the "pistol-shot" pulse 
with a to-and-fro hum (Duroziez sign). These peculiarities 
of the pulse are reflected in the pulse pressure which is increased. 

Except in the slightest lesions, the heart is enlarged, sometimes 
enormously so (cor bovinum), with the apex impulse in the seventh 
interspace at the anterior axillary line. The enlargement is 
connrmable by fluoroscopy and an increased amplitude of the 
aortic pulsation is then visible. Electrocardiography shows a 
left ventricular preponderance. 

In well marked cases the signs are clear cut and definite and 
mistake is unlikely. The diastolic murmur may simulate that of 
mitral stenosis but the pulse is corrective. Functional diastolic 
murmurs rarely occur at the base of the heart and are never 
accompanied by a collapsing pulse. 

A diagnosis of aortic stenosis is justified when there is a systolic 
murmur audible at the right side of the sternum in the second 
interspace, transmitted into the vessels of the neck and accom- 
panied by a palpable systolic thrill. Aneurysm may give rise to a 
similar murmur and thrill, and must be excluded. The probability 
of stenosis is increased if there be signs also of aortic insufficiency. 
The accessory signs are cardiac hypertrophy, and a pulse tracing 
showing a rounded or flattened peak. 

Organic disease of the tricuspid valves is rare and on account of 
the similarity of the signs to those of mitral disease is usually 
mistaken for it except in the most distinctive cases. With 
lesions of significant degree there is always dyspnoea, cyanosis, 
and usually oedema. 

Relative tricuspid insufficiency due to cardiac dilatation is 
frequently observed in the terminal stages of all decompensated 
cardiac disorders. The physical signs, whether due to organic or 
relative incompetence of the valves, are the same, differentiation 
depending on the nature of the case. Distention and systolic 


pulsation of the jugular veins with an enlarged liver in a cardiac 
disorder suggests tricuspid insufficiency. There is also a systolic 
murmur audible over the sternum at the level of the fourth space 
accompanied by a thrill which is, however, easily obscured if 
there be an accompanying mitral disease. The second pulmonic 
sound is lessened in intensity. The heart is enlarged to the right 
of the sternum, the area of dulness extending three or even four 
inches beyond the sternal margin. There are signs of chronic 
passive congestion at the bases of the lungs, or hydrothorax and 
general anasarca. 

The clinical picture produced by large pericardial effusions in 
children may simulate marked cardiac decompensation with tri- 
cuspid insufficiency. The cyanosis, orthopnoea, and oedema of 
the extremities due to embarrassed heart function, the dilated 
jugular veins and the displacement of the liver and extension of the 
right cardiac dulness present a complex very much like that of 
severe cardiac dilatation. 

Tricuspid stenosis is very rare.* It may be congenital or 

result from endocarditis. If no other valve is involved, tricuspid 
stenosis should be suspected when cyanosis and dyspnoea are 
accompanied by a rumbling diastolic murmur which is localized 
over the lower half of the sternum, and by a snapping first sound 
and presystolic thrill in the same region. The murmur is 
usually heard in mid-diastole rather than pre-systole, and the 
pulmonic second sound is diminished in intensity. When there 
is no evidence of cardiac failure an enlarged liver is a valuable 
accessory sign, as are an increase in the a wave in the graphic 
tracing of the jugular pulse, and increased dulness to the right of 
the sternum. In cases of long duration there is apt to be clubbing 
of the fingers and polycythemia. The murmur produced by 

* Of 173 cases of tricuspid stenosis collected by Osier and Gibson, in only 12 was 
the tricuspid valve alone involved; a mitral lesion is the commonest association. 


tricuspid stenosis is likely to be ascribed either to aortic insuffi- 
ciency or to mitral stenosis. 


Involvement of the pulmonary valves in endocarditis is exceed- 
ingly rare and its occurrence is nearly always in association with 
mitral and aortic lesions. Deformity of these valves may be a 
congenital malformation. 

Insufficiency of the pulmonary valves enters into consideration 
when a murmur is audible in early diastole, with or immediately 
following the second sound, heard best at the left sternal margin in 
the second and third interspaces and not associated with a water- 
hammer pulse. The character of the murmur and the area in 
which it is heard is identical with many cases of aortic insufficiency. 
This fact places the burden of differentiation mainly upon the 
character of the pulse and upon preponderant hypertrophy of the 
right ventricle. In lesions of the aortic valves when the amount 
of regurgitation is slight there may be no water-hammer pulse. 
A functional pulmonary insufficiency, due to dilatation of the pul- 
monary ring, in mitral valve disease produces the same signs as an 
organic lesion. This is the Graham-Steell murmur and it develops 
under conditions which produce dilatation of the right heart and 
pulmonary stasis. It has been noted in advanced mitral disease. 
The diagnosis of a Graham-Steell murmur should be made with the 
greatest caution. Diastolic murmurs attributed to functional 
regurgitation usually are found at autopsy to be consequent to 
aortic disease. 

A systolic murmur in the pulmonic area unassociated with any 
other sign of cardiac disorder is a common observation. These 
" accidental" or " hemic" murmurs are more often noted in thin 
chested individuals, or after exercise or excitement or during fevers. 
The murmur may be associated with respiratory phases, i.e. a 


cardio-respiratory murmur. Systolic murmurs in the pulmonary 
area are usually of no clinical significance. 

Pulmonary stenosis is nearly always a congenital anomaly. 
It is one of the commonest of the congenital cardiac defects, and 
is often associated with patency of the ductus arteriosus or a patent 
ventricular septum. Endocarditis implicating the pulmonary 
valves is usually either associated with other valve lesions or 
engrafted on an anatomically imperfect valve. Of the signs 
referable to the heart, a loud systolic murmur and a thrill in the 
second left interspace at the sternal margin or just to the left of it, 
are very like those of aortic stenosis. The murmur, however, is 
not heard in the cervical arteries and the electrocardiograph shows 
right ventricular preponderance. In congenital cases there is 
cyanosis and clubbing of the fingers and often polycythemia. 


Disease of the myocardium may be manifested by symptoms 
without signs or by signs alone. In the parenchymatous degenera- 
tion of the heart muscle which is generally met with in severe 
infections like typhoid fever, there are but seldom symptoms 
referable to cardiac function. In protracted or severe infections 
observation detects a change in the character of the apex impulse 
which loses force, and becomes more diffuse. The quality of the 
first sound is altered, "blurred," and not infrequently a systolic 
murmur is heard at the apex. This is not unusual with rheumatic 
fever, and the question of acute endocarditis is raised. The 
disappearance of the murmur during convalescence is not an infre- 
quent occurrence. A systolic murmur at the apex is met with in 
a majority of children during febrile disorders. Tachycardia, 
gallop rhythm, and epigastric pain in diphtheria are serious cardiac 
symptoms, and a drop in the pulse rate to 50 or 60 suggests grave 
myocardial disorder. 


Cardiac hypertrophy as a result of valvular disease or general 
disorder is not a cause of symptoms. Degeneration in the muscle 
is produced by infectious agents and toxins, by interference with 
nutrition (coronary endarteritis) or by the strain of severe phys- 
ical exertion. Degeneration may be diffuse and result in cardiac 
dilatation or it may be circumscribed in relatively small areas as 
in some cases of coronary artery disease. 

In general, the symptoms of chronic valvular disease are the 
effect not of the valve lesion but of dilatation. As shortness of 
breath, the earliest symptom of dilatation, reflects impaired 
oxygen and carbon-dioxid carrying power of the circulation, so 
the earliest signs reflect circulatory stasis, either passive congestion 
of the lungs or kidneys or both. The less severe degrees of dilata- 
tion are suggested not only by the symptoms but by an enfeebled 
apex impulse, a change in the character of murmurs already present 
or the development of a systolic murmur at the apex. Usually 
oedema of the ankles is detectable and albuminuria is present. 
There may be no change in the pulse or there may be tachycardia 
or arrhythmia. 

Grave dilatation as exemplified in the decompensation of 
valvular disease is characterized by orthopnoea, oedema or 
anasarca, a feeble pulse, usually irregular and with a pulse deficit 
and an enlarged area of cardiac dulness to the right of the sternum. 
The vascular stasis and passive congestion result in oedema, and 
hydrothorax, and an enlarged, perhaps pulsating, liver. Oedema 
of the lungs may be present and congestion may cause a blood 
tinged sputum. Acute cardiac failure and dilatation is met 
with in many conditions besides valvular disease, for example 
in Graves' disease, in primary hypertension, and in latent myocar- 
dial degeneration following excessive strain or surgical operations. 

Robust men in middle life may first come under observation 
with signs and symptoms of cardiac dilatation. The signs 


are those of hypertrophy with dilatation, often there is an irregu- 
lar pulse and a mitral systolic murmur. Dyspnoea and oedema 
are the chief symptoms. The blood pressure may be above 
normal notwithstanding the impaired cardiac function, indicating 
the cause of the primary hypertrophy. These attacks may be 
repeated over years, the irregular pulse being the only evidence of 
disease during intervals of freedom from symptoms. Anginal 
attacks may be the earliest symptoms. The periods of dilatation 
are sometimes remarkable on account of attacks of syncope or 
periods of mental disorder. 

The lesion in the myocardium may be chiefly focal and the 
best example of this is found in some cases of heart-block. There 
may be no evidence of dilatation and the only sign of the disorder 
may be bradycardia or arrhythmia. In some instances anginal 
attacks precede all other symptoms and there is no detectable sign 
of organic heart disorder. In many of these cases the electro- 
cardiogram reveals an abnormality suggesting an occlusion of a 
branch of a coronary artery. 

Many, if not a majority, of the cases of sudden death are 
due to myocardial disorder consequent to sudden occlusion 
of a main branch of the coronary arteries. These are the cases 
of "acute indigestion" spoken of in the newspapers. 


Acute fibrinous pericarditis is recognized by a to-and-fro fric- 
tion rub audible over the precordium and often accompanied 
by a palpable friction fremitus. The friction rub is most 
characteristic over the base of the heart but may be localized 
in any area. It is sometimes made more intense by pressure 
with the bell of the stethoscope. In pneumonia and rheumatic 
fever, especially, precordial pain arouses suspicion of pericarditis. 
Acute pericarditis of tuberculous or luetic origin is sometimes 


painless. In severe nephritis, and uraemic states, and as a 
complication of decompensated valvular disease pericarditis is 
common. The friction of pericarditis is to be differentiated from 
that of pleuropericarditis; the latter is usually influenced by- 
respiration and is less loud or vanishes on holding the breath. 
Occasionally loud endocardial murmurs are a source of confusion. 
Pericardial effusion should be suspected, (i) following acute 
pericarditis when the heart sounds become more muffled or 
the area of cardiac dulness increases; (2) in cases presenting 
symptoms of cardiac failure and a large area of precordial dulness 
but having a strong pulse; (3) when the precordial area of dulness 
is large although unaccompanied by corresponding signs of cardiac 
disorder. The signs which particularly indicate fluid in the peri- 
cardial sac are an increase in the cardiac dulness, and the shape 
of the area of dulness; obliteration of or indistinct apex impulse, 
especially if the pulse signifies an efficient heart action; and the 
distant, muffled character of the heart sounds. Obliteration of 
the cardio-hepatic angle (Rotch's sign) occurs in some cases but 
exceptions are so numerous that the sign is of little assistance. 
Large effusions are not incompatible with normal or nearly normal 
cardiac dulness. The effusion may extend posteriorly displacing 
and compressing the lung and producing an area of dulness in 
the left interscapular region (Bamberger's area) or both interscap- 
ular regions. The dulness may extend from the left interscapular 
region to the mid axillary line. When the effusion is large the 
liver is displaced downward and palpable. The signs are variable 
and the clue to the condition sometimes is found not in any sign 
but in an inconsistency between different signs or between signs 
and symptoms. The accessory signs are variable and often mis- 
leading. These are precordial bulging and obliteration of the 
intercostal spaces, elevation of the left clavicle, precordial friction 
and a pulse which is weaker during inspiration than expiration. 



The radiograph in some cases of pericardial effusion is quiet 
characteristic. The longest transverse diameter is lower than 
in the case of cardiac dilatation. The radiograph of a dilated 
heart, however, is occasionally indistinguishable from that of 

Fig. 31. — Pericardial effusion. In this case there were the usual signs anteriorly. 

The diagnosis of pericardial effusion is sometimes exceedingly 
difficult, and the condition is often overlooked. Signs at best 
only indicate an effusion; the determination is made by exploratory 
puncture. When the possibility exists of a massive effusion 
which embarrasses the heart or when there is a possibility of the 



liquid being pus then the use of the exploratory needle is obliga- 
tory.* The operation* is no more dangerous than exploration 
of the pleura, and can be made nearly painless for the patient 
by proper use of a local anaesthetic. The puncture may be made 
near the nipple line in the fourth or fifth interspace, at the right 
sternal margin in the fifth interspace or in the costoxiphoid 
angle close to the costal margin. Which site is most favorable 
depends on the apparent position of the heart. On several 

Fig. 32. — Pericardial effusion. In this case the signs indicating fluid were in the 

back. 700 c.c. aspirated from the back. 

occasions when there was pronounced dulness in the interscapular 
region I have tapped the pericardium in the left interscapular 
space. There was doubt in one case whether the effusion was 
pericardial or pleural. It was determined to be pericardial by 
injecting a sterile solution of methylene blue into the pericardial 

* "In at least three cases in our series we should have tapped the sac; post mortem 
the effusion was more than a liter." Osier, Practice of Medicine, 1909, p. 782. 


sac through the fifth intercostal space at the sternal margin 
and recovering a colored liquid by puncture in the interscapular 

When there is a suspicion of empyema of the pericardium as 
after pneumonia, the question should be decided by puncture. 
Timidity in tapping the pericardial sac costs many lives.* 

Adherent pericardium may be suspected as the cause of 
cardiac incompetency, (1) in young adults with marked cardiac 
hypertrophy when there is no apparent cause for the hypertrophy, 
(2) when cardiac symptoms are not associated with signs of 
valvular defect and have been preceded by acute pericarditis 
at an earlier period, (3) when there are signs of cicatricial 
mediastinopericarditis, (4) in a febrile polyserositis. 

Complete obliteration of the pericardial sac may occur with no 
sign other than cardiac hypertrophy. The signs which indicate 
chronic adhesive pericarditis are the signs of chronic mediastinitis. 
There is cicatricial union not only of the peri- and epicardium 
but also between the pericardium, the chest wall and the 
diaphragm. In consequence of these adhesions there results 
cardiac hypertrophy, and often the apex is fixed and not changed 
by the posture of the patient. The extent of the cardiac impulse 
is increased, and may be visible over the whole precordium. The 
impulse is undulatory from the sternum out and there is a systolic 
retraction of the apex region, and a palpable diastolic shock. 
When there are adhesions to the diaphragm there may be visible a 
systolic retraction in the area of the left para-sternal line and the 
seventh rib, and in the back at the eleventh or twelfth ribs on the 
left side (Broadbent's sign). There may be no visible respiratory 
movement in the epigastrium (due to adhesion between the heart 
and the central tendon of the diaphragm). The accessory signs 

* Empyema of the pericardium can be treated successfully by operation. See 
Pool. Annals of Surgery, 1921. 


are extremely variable and not often of much assistance. These 
are pulsus paradoxus, diastolic collapse of the cervical veins, and 
diastolic murmurs audible over the precordium. 

Adherent pericardium is often overlooked. On account of 
murmurs resulting from dilatation adherent pericardium may be 
mistaken for an endocardial lesion. The diastolic murmur found 
in about one fifth of the cases is particularly apt to be misleading 
in view of the existing cardiac hypertrophy. In a series of 24 
cases of adherent pericardium with no evidence of valvular lesion 
at autopsy, 7 had been diagnosed as aortic insufficiency on account 
of diastolic murmurs and hypertrophy. 

When there is chronic proliferative peritonitis associated with 
adherent pericardium (Pick's disease*) ascites may be the promi- 
nent symptom for years, and in the absence of definite cardiac 
disorder, lead to the diagnosis of cirrhosis of the liver. 


In the early stages of the primary disorder, both cardiac hyper- 
trophy and vascular hypertension may be unattended by symp- 
toms. Hypertension is often an " accidental finding " in the course 
of an examination. Many cases are first discovered by life insur- 
ance examiners. The detection of either cardiac hypertrophy or 
hypertension alone or in association is a sign of sufficient impor- 
tance to justify careful search for the primary cause. The usual 
cause is chronic nephritis. But chronic nephritis can not be 
assumed to be the cause in every case since there are many excep- 
tions. In the first instance the type of hypertension is of some 
importance. Hypertension is spoken of commonly as though it 

*A mid-western brewer whose name was famous in a bygone day had for years 
recurring ascites requiring occasional tapping. Because of his fondness for cham- 
pagne the disorder was assumed by all of his numerous physicians to be cirrhosis 
of the liver. Finally he died and autopsy revealed chronic adhesive pericarditis, 
periphepatitis, perisplenitis, etc. — Pick's disease. 



were a single thing, variable only in degree. As a matter of fact 
there are several types. There are two factors in blood pressure, 
two pressures; the systolic or maximal and the diastolic or mean- 
pressure, and either one alone or both together may be elevated 
above normal. For adult men the systolic pressure normally does 

Day of Dieeasc 

















t "?/H> f g 

12. tf s 


140 mm 

*♦-• :::::.' 

50 mm 

■*~~-#' *%--^~ 

: . : . 

i : : : : ]|[ _j 

Fig. 33- — Normal blood pressure. Man of 52 years, in bed on account of fracture 

of the femur. 

not exceed 140 m. m. of mercury and the diastolic 85 m. m. In 
women these pressures are usually about 10 m. m. lower. So many 
factors influence arterial tension (posture, exercise, mental excite- 
ment, etc.) that the routine estimation made in the course of the 
first examination has only a relative value. For reliable data the 



patient should be kept at rest in a recumbent posture for at least 
fifteen minutes before the estimation is made. Mental tranquility 
is also important, but difficult to secure. 

The auscultatory method of blood pressure determination is 
the only one generally recognized as reliable. In estimating 


Day of Disease 






























250 mm 







i 180mm 



150 mm 










50 mm 







Fig. 34. — Type of hypertension, systolic pressure elevated, diastolic pressure nor- 
mal. (Fall of systolic due to rest in bed.) 

blood pressure by this method, the bell of the stethoscope is held 
on the skin over the brachial artery at the elbow and about three 
inches below the cuff of the sphygmomanometer. As air is 
pumped into the cuff the pulse is heard as sharp " thumps," the 
pressure is increased slowly till the pulse sounds disappear. Then 



the air is allowed slowly to escape by opening the vent cock. The 
pressure at which the sound first returns is the systolic pressure. 
As the pressure is further reduced there comes a point when the 
pulse sound suddenly changes from a sharp "thump" to a more 
distant and muffled sound. This point is the diastolic pressure. 
At a somewhat lower pressure the sound vanishes. 

Day of Disease 


j n, 




it in Hi 

r tut 



n U 



ii u 




■ ■ ■ .. 








150 mm 










50 mm 


U h. 




: • k \ 

| : : I : . . 

X ' i 


■ " ■ I 



\ : '■ 











' i 





Fig. 35. — Type of hypertension. Systolic and diastolic both elevated, 
systolic pressures often noted in nervous patients. 


The special examination of the class of cases under considera- 
tion is best begun by examining the retinal arteries. Early 
stages of arteriosclerosis are nowhere else so definite as in the 
arteries of the retinae; moderate degrees of thickening of the 



radial and temporal arteries are difficult to detect and their signifi- 
cance debatable. One also scans the retinae for scars of hemor- 
rhages and exudate. 

It is difficult to say at the present time what functional tests 
are best adapted to discover the incipient stages of chronic nephri- 


Day of Disease 






1 i> 

v i 










» V i 8" « V 



• : 





-A <•»- 

ifn^i pf ]h 

50 mm 



:'.:.• : 



Fig. 36. 

-Hypertension due to chronic nephritis and uremia. Gradual fall of 
blood pressure due to rest and improvement in condition. 

tis. The diagnosis of advanced cases, when in addition to symp- 
toms there is nocturnal polyuria, urine of low specific gravity, 
marked retardation of the phenol-sulphon-phthalein excretion and 
some retention of nitrogen in the blood, is easy and definite. 
Albuminuria may be due to so many causes that it is of little 


value in diagnosing nephritis. The absence of albumen in several 
specimens does not exclude nephritis, and the same statement may 
be made concerning granular casts. But some relatively simple 
tests will serve to discover the nature of the renal disorder and its 
degree of severity in a majority of the cases. Exceptional cases 
may escape detection in any routine, and the recognition of them 
depends on the acuteness of the clinician and his resourcefulness 
in devising methods to meet particular requirements. 

Only a minimum of laboratory equipment and time is required 
for "concentration tests." The patient takes his regular diet, but 
the amount of fluid ingested is limited to one liter a day (this 
fluid includes not only water but soup and milk) . Coffee and tea 
are excluded because they are diuretics. Beginning at 10 a.m. on 
the first day of the test, the patient empties the bladder every two 
hours into separate bottles. The night specimen from 10 p.m. 
till 8 a.m. is saved as one specimen. These several specimens are 
tested for specific gravity, albumen and casts. The total volumes 
of the day and night specimens are measured and compared. 
The day specimen should measure more than the night and the 
night specimen should not exceed a liter. The object of this test 
is to discover whether the kidneys are able to excrete a concen- 
trated urine. With limitation of the water ingested the specific 
gravity under normal conditions will rise, the several specimens 
may show a range from 1.012 to 1.030. In definitely advanced 
cases of nephritis, for example, the range may be only from 1.008 
to 1. 014; and the night urine may be of low specific gravity and 
large volume. This form of test which Mosenthal has formulated 
into a workable routine serves only to show whether the kidney 
can meet a limitation of water by excreting its products in con- 
centrated form. It is a test of the latitude of excretion of salts. 

Another way of determining the concentration function gives 
more definite results, and is especially useful when it is desirable 


to reduce the protein in the diet and note the effect. The patient 
is given a diet of cereals (rice, hominy grits, and breakfast foods) 
butter and sugar (or syrup) . This is in effect a low protein diet. 
No water or liquid other than that in the diet is permitted. In 
normal persons the specific gravity of the urine will rise to 1.025 or 
1.030 within 24 hours. The specimens of urine may be collected 
the same as in the preceding test. The ratio of night and day 
volume is particularly to be noted. 

A kidney may have considerable restriction of this latitude and 
still meet the required demands of freeing the body of nitrogenous 
waste and excess salts provided there is no impairment of water 
excretion. This can be shown mathematically, and has been 
demonstrated to be true in some cases of nephritis at the New 
York Hospital. A normal person may excrete 1200 c.c. of urine 
containing two per cent of urea, or 24 grams. On the other hand 
a case of nephritis may show on test that the kidneys can not 
excrete urea in any concentration over 1 per cent. But if the 
water-excretion be not impaired the elimination may be perfect. 
This is a sort of power of compensation. 

1200 c.c. X .02 = 24 
2400 c.c. X .01 = 24 

It is evident then that the prognosis depends on the determination 
of the water-excretion function as well as upon concentration 
tests. The usual method of procedure in the water-excretion test 
is to have the patient drink 1500 c.c. (approximately 6 glassfuls) 
of water during half an hour. The urine is collected for the next 
two hours. A normal person will excrete from 700 c.c. to 1000 c.c, 
and the specific gravity of the specimen will fall to 1 .005 or 1 .003 . 
This may also occur with some cases of nephritis. When water is 
excreted poorly it is a valuable fact to be borne in mind in progno- 
sis. However, in a test of this type not only renal function per se 


is concerned, but also the rate of absorption from the digestive 
tract, and especially the heart function. Cases of cardiac in- 
sufficiency usually respond abnormally, the urine volume being 

The phenol-sulphon-phthalein test has met with general accep- 
tance and requires very little equipment. A standard syringe 
that will deliver exactly i c.c. and some form of colorimeter* 
is all that is needed. Exactly i c.c. of the test solution is injected 
into a vein or into the deltoid or lumbar muscles. Subcutaneous 
injections are sometimes accountable for abnormal results. 
The urine is collected for two hours, made alkaline and the 
amount of dye excreted is estimated. It is found in practice that 
impaired excretion of phenol-S-phthalein goes hand in hand with 
impaired excretion of urea and other nitrogenous bodies found in 

When any of the substances normally excreted from the body, 
fail of excretion they accumulate in the tissues and in the blood. 
The simplest test based on this fact is the estimation of the urea 
in a sample of blood withdrawn from a vein in the arm. Signifi- 
cant increases in the blood urea usually indicate advanced degrees 
of renal degeneration. Severe cardiac decompensation may be 
responsible for an increase in the blood urea by impairing the 
renal function — passive congestion. There is some evidence to 
suggest that uric acid is poorly excreted at an early stage of nephritis 
while the urea-excretion is still unimpaired. If matured experi- 
ences prove this to be a fact then an increase of uric acid in the 
blood will no longer be a peculiarity of gout, and there will be 
added support for an old theory that gout is primarily a renal 

A number of terms descriptive of renal phenomena have come 
into general use during the last decade. There is some danger 

* The convenient and simple Dunning test set is inexpensive. 


that these terms may be thought of as possessing the dignity of 
physiological laws rather than being merely descriptive of 
commonly observed conditions. Thus we speak of "failure of 
concentration/' If one will observe carefully the effect of infec- 
tions associated with fever upon the concentration of urine in 
definite cases of contracted kidney it will be evident that under 
some conditions at least concentration function is not abolished. 
Nor is good concentration an invariable sign of healthy kidneys. 
Some cases of chronic nephritis seem never to be characterized by 
urine of low concentration or by polyuria. In other respects the 
signs may be typical. Several instances of this sort have come to 
my attention, where cardiac or other complications could be 
excluded, the remarkable facts being absence of polyuria and noc- 
turia, and the high specific gravity range of the urine (over 1.020 
in all, up to 1.030 in one case). Two such cases died of epilepti- 
form uremia. Diagnosis was confirmed by autopsy. 

The fact is that with due care nephritis can usually be recog- 
nized in well developed instances of the disease. Definitely to 
exclude nephritis is impossible with our present knowledge. 
Every student of the disease has met with humiliation at the 
autopsy table. A kidney is composed of several millions of 
glomeruli and tubules, each one of which is really a single organ. 
Many of these renal elements may degenerate and atrophy, and 
still leave a surplus of' healthy elements. The loss of one kidney 
is a trivial episode so far as renal function is concerned — that is 
loss of half the glomeruli. I could detect no decrease of function, 
even with the severest tests in a young man who had had nephrec- 
tomy on account of an injury. 

These comments seem necessary in view of the atmosphere 
of mathematical certainty which pervades some of the literature 
of the subject 


There are four main causes for digestive disorders which must 
constantly be borne in mind: (a) organic disease (e.g. cancer, 
ulcer, etc.), (b) reflex symptoms from disease outside the tract 
proper (pelvic disease), (c) functional disorders (neuroses, con- 
stitutional types, etc.), (d) systemic disease (tuberculosis, cardiac 
disease). While the functional group is numerically a common 
cause of gastro-intestinal symptoms, this fact must not lead to 
preconceived ideas in individual cases. A life long dyspeptic may 
develop a cancer. Every patient over 40 with gastro-intestinal 
symptoms deserves careful examination to exclude cancer. The 
diagnosis of gastric neurosis should never be entertained until all 
methods of detecting organic disease have been exhausted, indeed 
the diagnosis can not be otherwise established. 

An analysis of a series of cases whose symptoms were primarily 
and chiefly those of a digestive disorder gave the following results: 

Organic Disease 389 14% 

Neoplasms 84 

Ulcer 305, 

Reflex Disorders 1105 39% 

Adhesions and appendicitis 522 

Gall bladder and liver 397 

Constipation 138 

Pelvic disease 48 

Systemic Disease 465 J 6% 

Kidneys 1 54 

Cardio-vascular • • • i° 2 

Pulmonary 88 

Blood and ductless glands 53 

Organic nervous disease 3° 

Infections 3 8 



Functional Disease 620 22% 

Neuroses 384 

Constitutional asthenia 71 

Achylia 123 

Migraine 42 

Diagnosis undetermined 186 6% 

There are certain facts in the history which have proved them- 
selves of especial value in diagnosis. In the past history, typhoid, 
jaundice (relation to gall stones), appendicitis, operations (adhe- 
sions), tuberculosis, syphilis, infections of the tonsils and sinuses, 
nervous breakdowns, insomnia, headaches (neuroses) are impor- 
tant. In some cases the habits of the patient and the conditions 
of home and social life are significant. I have found the chro- 
nological history devised for psychic disorders by Adolph Meyer of 
great help in the diagnosis of functional digestive disorders. One 
obtains first from the patient a careful record of the development 
of the attacks, then ascertains, as exactly as possible, the dates of 
onset of these attacks. Note their dates in one column. Then 
review with the patient her personal life. This is really a psychic or 
emotional record and tact must be exercised to secure facts. 
Often it is better to have this conversation take place after the 
examination is concluded and appear to have no professional 
relation whatever. And if notes are made of dates or events, it 
must be done surreptitously. The patient must be off guard and 
en rapport. The following record is that of a neurotic woman with 
gastric reactions. 

1st attack, nausea, anorexia, June- July, 191 1 Death of father. 

pain in abdomen, in bed 

two weeks. 
2nd attack, constant nausea, October, 1914 Family quarrel over father's 

took no food, only water, estate. Lawsuit. 

pain, bed a week. 
3rd attack, nausea, some vomit- August, 1919 Unsatisfactory decision of 

ing, constant gastric pain, lawsuit. 



In analyzing the patient's symptoms it is necessary to form a 
clear idea in order to estimate their degree of importance. Some 
symptoms are of major importance since they are more apt to 
indicate organic disease; pain, loss of weight, vomiting, bleeding 
are of this class. With respect to pain, its character, whether 
constant or in attacks, the location of the pain and its radiation, its 
occurrence before eating, just after or hours after eating, and what 
if anything the patient has found to relieve the pain; these are all 
notable facts. 

Inquiry should be made about vomiting in order to ascertain 
its frequency, relation to meals and the character of the vomitus 
(food, blood, pus, mucus). Is there dysphagia or regurgitation? 

In respect to bowel action, information is sought relative 
to painful defecation, diarrhoea, constipation and the character 
of the feces (color, blood, mucus, undigested food, etc.). 

The general condition of the patient bears upon the duration 
and severity of his disorder and is reflected in loss of weight and 
strength, ease of fatigue and nervous irritability, and these in 
turn have been in some measure influenced by his appetite, 
and whether his diet has been restricted or not. In both organic 
disease and neuroses attended with discomfort patients frequently 
restrict their food and, as a consequence, lose weight, even to becom- 
ing emaciated. This emaciation is often attributed to the disease 
when in reality it is a consequence of inadequate food. The 
inclinations and preferences of patients and their aversion to 
classes of food is also helpful at times, especially in cases of 

In taking a history of a case and making the examination 
alike the aim constantly in mind is to detect the earliest degrees 
of serious organic disease. Carcinoma of the gastro-intestinal 
tract is usually recognized too late for successful surgical treatment. 
And the majority of cases of ulcer first undergo treatment for 


functional disorder. A careful analysis of the symptoms is of 
major importance and often discloses the most significant data 
obtainable. Gastro-enterologists and surgeons agree that of the 
various methods of diagnosis the most important is the history. 
Osier was fond of telling of a case of gall stone in the ampulla 
which was correctly diagnosed by his secretary over the telephone. 

Since digestive disorder may give rise to the chief symptoms of 
remote disease, the general examination should be conducted with 
all thoroughness. Every consultant sees cases of tabes which have 
not been relieved of crises by operations for gall stone. For 
the examination of the digestive tract there are available the 
following methods : (a) the history of the disorder, (b) the physical 
examination in general, (c) X-ray examination, (d) functional 
test — test meals either to be removed from the stomach for analy- 
sis, or to be allowed to traverse the tract for examination of the 
feces, (e) laboratory test of gastric and intestinal contents, and 

Formerly much reliance was placed on test meals and gastric 
analysis. Today the importance of the gastric analysis in 
ulcer and neoplasm has been largely supplanted by fluoroscopy 
and an appreciation of the value of good clinical histories. Chan- 
ges in acidity of gastric secretion result from numerous causes, 
hence the mere demonstration of achlorhydria or hyperchlorhydria 
is at best only supportive evidence. The result of analysis 
of a single test meal is often worthless because the emotional 
reaction of the patient may change entirely the amount of secre- 
tion and motility of the stomach. And "fractional tests" 
have overcome no deficiencies in the method. The increase 
in our understanding of gastric physiology has shown that there 
are wide variations in the normal (Rehfuss) and also that 
different portions of the stomach contents removed simul- 
taneously may show different degrees of acidity. In other words, 


there is a large experimental error inherent in the method. 

First of all then is a complete clinical history and next a 
thorough examination to exclude disease elsewhere in the body, 
the abdominal examination being done last. v 

The Mouth. — It is logical to begin examination of the gastro- 
intestinal tract at the mouth. A patient may have a number 
of good teeth but an inadequate number of apposing molars 
for mastication. Pyorrhoea alveolaris, or devitalized teeth 
which harbor apical abscesses may play important roles as focal 

Fig. 37. — Leukoplakia and carcinoma of the tongue. 

infections. A coated tongue is quite as apt to indicate infection 
in the nose, sinuses or tonsils as a disordered stomach. Areas 
of leukoplakia suggest a search for signs of syphilis and a Wasser- 
mann test of the blood. The mere appearance of the tonsils 
is often misleading. Large, protruding tonsils in adults are usually 
infected, but small tonsils may be infected. It is difficult, often 
impossible, to decide by examination whether a tonsil is signifi- 
cantly diseased. If there is a history of frequent sore throat 
infection is probable. Secretion can sometimes be expressed 


from the tonsil by massage with the finger. Or the anterior 
pillar may be pushed aside with a stiff probe and pressure made 
upon an area near a crypt. A blunt glass rod, the size of a lead 
pencil, is a handy instrument with which to press out tonsillar 
secretions. "Plugs" of secretion, the size of a grain of rice, 
can sometimes be expressed from a crypt. Enlargement of the 
lymph nodes in the neck along the anterior border of the mastoid 
muscle may result from chronic infection of the tonsils. Some 
of these tonsillar infections are tuberculous. 

In two diseases with gastro-intestinal symptoms important 
data for diagnosis result from examination of the mouth — sprue 
and plumbism. When a painter develops gastro-intestinal symp- 
toms, one looks first for a "lead line" in the gums. But lead 
poisoning is not always so evident a possibility. A woman of 
indefinite age consulted several physicians for relief from attacks 
of abdominal pain and vague pains in the arms. She was treated 
for "nervous exhaustion," and suspected of having gall-stones. 
After several physicians had failed to relieve the patient, someone 
thought he saw an indefinite lead line. Electrolysis demonstrated 
lead in the urine and a simpler chemical method convicted the 
face powder. 

When plumbism is suspected the blood should be examined 
for stippling. Lead may be isolated from the urine. 

The "peculiar, inflamed, superficially ulcerated, exceedingly 
sensitive condition of the mucous membrane of the tongue and 
mouth" (Manson) is characteristic of sprue. In early stages of 
the disease there may be no ulceration, only a raw, swollen appear- 
ance. This lesion, with the history of diarrhoea and the character 
of the stools, suggests the diagnosis. 

The Esophagus. — Inflammatory lesions of the esophagus are 
uncommon and usually a complication of acute infections (diph- 
theria, small-pox). The commoner conditions met with are 



various types of stricture. A simple spasm may occur in neurotic 
subjects and is recognized by the relation of attacks to emotional 
storms. The commonest causes for stricture of the esophagus 
are neoplasm (80%), cicatrix of healed ulcer (syphilis, corrosive 
poisons); and pressure from mediastinal tumors (lymph nodes, 
aneurysm) may also produce stenosis. Examination to determine 

■ ^ - .. 


Fig. 38. — Carcinoma of the esophagus with stenosis. 

stenosis is best done by means of fluoroscopy. One then sees at 
once the site of the constriction and its degree. When fluoroscopic 
examination can not be carried out, considerable information 
may be derived by passing sounds. This should be done with 
great care. Instances of rupture of an ulcerated oesophagus 


by a bougie are recorded. The bougie is passed like a stomach 

The Abdomen. — Accessibility for examination causes special 
attention to be directed to the abdomen and palpation is the 
chief method. Percussion has only a very limited usefulness. 
The outline of the stomach even, can be determined with no 
exactness, since the colon tympany is so often a confusing factor. 
The size of the stomach after inflation is as likely to represent its 
degree of atony as anything else. 

In palpating the abdomen one is seeking for changes in muscle 
tone, and muscle spasm, areas of sensitiveness and tumor masses. 
Patients vary in sensitiveness, some are hyperaesthetic generally 
and this has to be taken into consideration. If the clinical history 
suggests that some area of the abdomen will be sensitive, this area 
should be palpated last. Muscle spasm induced by painful palpa- 
tion is not readily overcome and may frustrate the examination. 
Begin abdominal palpation by placing the palm lightly on the 
abdomen. Determine, first, muscle tone by gently flexing 
the fingers without moving the palm of the hand. Only the ringers 
should be used. Thus passing rapidly over the whole abdomen 
either muscle rigidity or increased .tonicity in any area is quickly 
revealed. Next with the finger ends, the palm not touching the 
abdomen, gently and slowly make pressure on each side of the 
abdomen alternately, noting any tendency of the muscles under 
the fingers to stiffen as pressure is made. The local increased 
resistance to pressure is one of the earliest signs of inflammation. 
Pressure sufficient to elicit resistance need cause no pain whatever. 
By this type of examination information is gained as to the 
character of a lesion and its general location — i.e., which quadrant. 

The palpation of the abdominal organs and tumors is done 
last, because deep pressure is usually required and may induce 
muscle spasm. If the examiner proceeds slowly and carefully it 


is possible to outline tumor masses even when there is marked 
sensitiveness. Placing the hand on the abdomen, the patient 
is directed to breathe in slow deep breaths. At each expiration 
the palpating hand can sink a little deeper into the abdominal 
wall. The respiratory movements also aid in determining with 
what organ a mass is connected. Palpating the lumbar regions — ■ 
e.g. for movable kidney — is best done with one hand posterior, so 
that the two hands may be slowly drawn together. If a tumefac- 
tion be felt the significant facts for determination are its size, 
shape and consistency (solid or cystic) and the organ with which 
it is connected. The last point can seldom be determined directly, 
but depends on deduction from probability, considering the age 
of the patient and the history of the disease. The probable 
nature of these abdominal tumors is a matter of statistics. The 
frequency of various diseases varies in different countries and even 
in different localities within a country, so that statistical data 
are not invariable but serve as a guide only within limits. When 
a mass is felt or the shape and size of an organ is changed the 
commoner causes for this phenomenon flash through the mind. 
Diagnosis is largely by exclusion, seldom direct, and for exclusion 
the possibilities must be known. It is appropriate to review a 
few of these categories in relation to palpation of the abdomen 
in cases of disease of the gastro-intestinal tract. 

For convenience of description, the abdomen is divided into 
four quadrants. Beginning with the right upper an enlarged 
liver may be noted. The first question for answer is : Is the liver 
really enlarged or is there ptosis? This would be determined by 
the location of the upper border. The common causes of a large 
smooth liver are (a) chronic passive congestion (cardiac), (b) 
fatty cirrhosis and (c) amyloid disease. Or the liver may be 
enlarged and irregularly rough — neoplasm, syphilis (especially 
left lobe), abscess. 


The commonest masses detected in this quadrant are movable 
right kidney and distended gall bladder. The gall bladder may 
be surprisingly low down and then it is apt to be mistaken for some 
other tumor, e.g. neoplasm of intestine. The common causes of 
enlarged kidney are neoplasm, tuberculosis and hydronephrosis. 

In the left upper quadrant enlarged spleen is the commonest 
tumefaction, and exceptionally neoplasms of the stomach, pan- 
creas and colon present here. Enlargements of the spleen are 
usually due to typhoid, malaria, the anaemias, leukemias, and 
cirrhosis of the liver. 

In the mid-line the commonest tumor in young people is due 
to tuberculous peritonitis; in individuals over forty years of age 
carcinoma of the stomach, duodenum or pancreas. 

Masses in the right lower quadrant are apt to be (a) abscess 
secondary to appendicitis, in women tuberculous peritonitis and 
pyosaipinx; carcinoma of the intestine and intestinal obstruc- 
tion. In both lower quadrants abscess and tumors of tubes and 
ovaries are common in women and in the median region fibromata 
of the uterus. 

In the left lower quadrant, excluding the commonly palpable 
distended colon, neoplasms are felt and occasionally masses due to 

The Rectum. — The general examination of cases of gastro- 
intestinal disease is never complete without examination of the 
rectum. Worth remembering is a pithy remark of Sir Benjamin 
Brodie that the function of the consultant is to make rectal 
examinations. Carcinoma of the rectum is common and is not 
rare in early life. Metastases in the peritoneum and liver are 
often mistaken for primary tumors. The object in examination 
by rectum is primarily to detect signs of induration or thickening 
suggesting carcinoma either in the rectal wall or prostate, local- 
ized sensitiveness (ulcer, ischiorectal abscess), stricture (usually 


leu tic) or thickening of the seminal vesicles.* — (See Rectal 

If there be suggestion of ulcer in the rectum, or if there be a 
history of chronic diarrhoea or blood in the stools the rectal 
examination should be supplemented by use of the sigmoidoscope. 
The modern instrument with electric illumination requires but a 
modicum of skill. 

Chronic diarrhea, associated with attacks of intestinal colic is 
suggestive of ulcerative colitis. Blood is usually present in the 
stools. The sigmoid is sensitive and thickened. The diagnosis 
may be suspected but can be confirmed only by sigmoidoscopy. 

A complete study of the gastro-intestinal tract includes func- 
tional tests and a radiographic examination. These examinations 
supplement each other, one shows secretory activity chiefly while 
the other shows form and motility. The gastric test meal belongs 
to the first class. The standard test breakfast of i slice of stale 
bread and i J^ glasses of water is given after extracting the fasting 
contents from the stomach. There are many variations in the 
type of stomach tube employed and in the technique of extrac- 
tion. A small tube is as easily used as a large one and less objec- 
tionable to the patient. Spraying the throat with 2 per cent, 
novocaine relieves nervous patients. The facts of moment 
revealed by a test meal are the amounts of free hydrochloric acid, 
the total acidity and the presence of absence of blood, pus, and 
mucus. Marked departures from normal motility can be demon- 
strated by means of the stomach tube but not slight retention. 
There is no single fact revealed by the test meal which is a pathog- 
nomonic sign. The significance lies in the accordance of test 
data with all other data. Achylia does not indicate cancer, nor 

* Occasionally renal colic simulates acute appendicitis. The engorgement of 
the seminal vesicles on the right side which occurs along with renal colic is some- 
times helpful in differentiation. 


hyperchlorhydria ulcer, each is a single sign — nor should they 
be spoken of as diseases in themselves.* 

The fractional-extraction method is probably more generally 
used today than the older procedure of emptying the stomach at 
the end of an hour. But it is doubtful whether any added informa- 
tion is gained by aspirating samples at quarter-hour intervals. 
These samples do not necessarily represent conditions in the whole 
stomach content. For fractional extraction the patient swallows 
a small tube with a perforated metal tip. Several models of this 
duodenal tube are on the market. The tube is easily swallowed 
without discomfort to the patient. There is a mark on the tube 
indicating the distance from the teeth to the stomach, and when 
the patient has swallowed enough of the tube so that the mark is 
between the teeth the end of the tube is well in the stomach. The 
fasting gastric contents is first aspirated by means of a glass 
syringe. The patient then takes a slice of bread and a cup and a 
half of water or weak tea (no butter, sugar or milk). Beginning 
fifteen minutes after the patient has finished eating, samples are 
aspirated at quarter-hour intervals. Seldom more than five 
samples can be secured, the stomach having become empty. 
These separate samples are examined for acidity and for abnormal 
elements — blood, pus, etc. A curve may be plotted showing the 
acidity range. There is considerable normal variation. The 
method in my experience has not been very satisfactory. The 
truth is, probably, that internists rely less now on data secured 
from test meals than formerly, largely because of the use of 
fluoroscopic examinations. This is the case in our New York 
Hospital Clinic, and accuracy in diagnosis has improved. In a 
considerable series of cases where Arthur Holland's diagnosis was 

* An analysis of a series of cases of gastric cancer reported from the Mayo 
Clinic, indicates that achlorhydria was found in about half the cases; normal or 
hyperacidity in more than one-quarter of the cases of gastric cancer. 


proved by operation error was below 3 per cent, in the last two 

A test meal consisting of considerable amounts of meat and 
fat may sometimes be of use in determining pancreatic function, 
but the presence of lipase and trypsin is best detected by 
testing the duodenal contents. The fatty stool containing 
undigested meat fibre and the absence of lipase in the duodenal 
secretions are, however, indicative of a severe degree of pancreatic 
disease. The earlier and less defined stages are not revealed 
by any known test. In my experience these tests of pancreatic 
function have been helpful only in the diagnosis of a few cases 
of carcinoma of the pancreas. The patient swallows the duodenal 
tube in the same way as for extracting gastric contents. More 
of the tube has to be swallowed of course. Usually gastric 
peristalsis will carry the tip of the tube past the pylorus. A 
half hour or more may be required. When the tip of the tube 
is in the duodenum the aspirated sample will be yellowish in color 
and of alkaline reaction. The duodenal contents may be examined 
for the presence of lipase and trypsin in suspected pancreatic 
disease, and for pus cells and crystalline material in cases of 
suspected cholecystitis (Lyon's tests) . 

Radiographic Examination. — Fluoroscopic examination is in 
general much more instructive than the study of numerous 
x-ray plates. Both require skill and practice. The examination 
of oesophagus, stomach and duodenum should be preferably 
fluoroscopic. Gall stone shadows are more easily detected in 
plates. And it is to be remembered that a gall stone will cast 
a shadow only when its calcium content is over 30 per cent., 
therefore there is no such thing as exclusion of gall stones by 
radiology. In suspected stenosis or diverticulum of the oesopha- 
gus the recognition of the condition by fluoroscopy is easy and 
quick. Examination of the stomach and intestine gives the most 



valuable information in those diseases associated with changes 
in motility and deformity. Fluoroscopy has here a signal advan- 
tage over a series of plates because the moving shadow is seen 
and accidental distortions may be corrected by pressure with 

Fig. 39. — Tuberculosis of the cecum and ascending colon showing the character- 
istic filling-defect. Diagnosis confirmed by operation. (Case from the Trudeau 
Sanatorium. ) 

the hand on the abdominal wall, thus pushing the opaque emulsion 
where the examiner wishes. Considerable skill and experience, 
however, is required in order not to be misled by variations 


in the normal. Even in experienced hands early cancer may fail 
to be detected by x-ray examination. In general, ulcer of the 
stomach and duodenum, and carcinoma in stomach or intestine 
are easily recognized by the trained fluoroscopist. In addition 
it should be possible to state on the basis of fluoroscopic examina- 
tion that a disorder is due to reflex spasm. 

Radiographic examination of the intestinal tract is indicated 
when there is suspicion of changes in motility, adhesions, ulcers 
or neoplasm. The experience at Saranac shows that tuber- 
culosis of the intestine is also recognizable in a majority of the 

The Feces. — No examination of the gastro-intestinal tract 
is complete without thorough examination of the feces. The 
putty colored, acholic stool and the fatty stool of pancreatic 
disease are characteristic in appearance. The patient must have 
been on a meat free diet before tests for blood become reliable. 
Chemical tests for bile derivatives may be required in exceptional 
cases, but the elaborate estimations of fat and fatty acid once 
in vogue have been found of no value and often misleading. 
Microscopic examination is required to detect parasites and ova 
and pus. Amoebae are found most readily by examining a fresh 
particle of bloody mucus recovered by the use of a rectal 

In diarrhoeal diseases the chief alterations in the character of 
feces are due to the rapidity of passage through the intestinal 
tract. Food has not time for digestion and appears in recognizable 
states, bile is but slightly changed, fermentation occurs because 
there is fermentable material and the reaction is favorable. 
Finally it is not sufficiently appreciated that the normal stool is 
largely composed of bacteria and always contains mucus if sub- 
jected to chemical test. When there is constipation the formed 
feces remain abnormally long in the colon and mucus is evident 


on the surface of the stool. This mucus is sometimes regarded by 
the ignorant as evidence of colitis. This type of " colitis" is 
cured by a diet containing much indigestible residue as Von 
Norden pointed out years ago. 

In children the complications of the diarrheal diseases are very 
important. Two especially require mention, acidosis and dehydra- 
tion. In fact these conditions go together. Dehydration results 
from water loss and inability to retain fluids. The infection and 
deprivation of food depletes the glycogen stores of the body so 
that life is maintained by fat combustion. Acidosis results. The 
signs which should excite attention are rapid wasting, deep, slow 
or rapid shallow respirations (increased pulmonary ventilation) 
somnolence and stupor. Tests of either blood or urine will give 
helpful information. Appropriate treatment, saline solution or 
saline with glucose intravenously or intraperitoneally often works 
a miracle. 

Special diets are seldom necessary preliminary to examination 
of feces, unless the patient be on some self-imposed regimen. The 
color of the stool is altered in pancreatic disease and when the flow 
of bile is obstructed. Stools of pancreatic disease are bulky and 
greyish due to excess of neutral fat (if the diet is normal). 
Acholic stools likewise contain fat excess because fat digestion is 
inhibited when bile is absent. These stools are " putty colored." 
Stools of pancreatic disease show bile pigments on test. They are 
peculiarly fetid. Carcinoma of the head of the pancreas may 
compress the bile-duct causing jaundice and acholic stools. The 
jaundice is then progressive as in carcinoma of the bile-ducts. 
Acholic stools from obstruction occur exceptionally without 
jaundice. It is supposed the inflammatory process extends to the 
liver cells and bile is not secreted. I have seen three cases of this 
sort. One patient recovered following operation and drainage of 
the gall-bladder. 


In suspected disease of the pancreas the feces should be 
examined microscopically for undigested muscle fibres and 
undigested nuclei of muscle cells. The Cammidge reaction in 
the urine has not proved of value. 

The commoner causes of melena are peptic ulcer, carcinoma, 
cirrhosis of the liver, and the haemorrhagic diseases. Hemor- 
rhage from the bowel may be a conspicuous symptom in chronic 
nephritis. It has been mistaken for the melena of cancer of the 
bowel. Occult blood is present in the stool in many cases of 
ulcer and cancer. The patient should be on a diet containing no 

meat for forty-eight hours before the tests are made and examina- 
tion of the mouth must be made to exclude sources of bleedings.* 
Mucus is recognized in the macroscopic examination of the stool. 
In considerable amounts it suggests (a) catarrhal enteritis, (b) 
ulceration or cancer of the colon or rectum, (c) neurotic constipa- 
tion (mucous colitis). Small pieces of mucus are to be found in 
every diarrhoeal and dysenteric stool. When mucus is present 
the stool should be examined for pus, blood, and scraps of tissue in 
order to decide whether there is ulceration. 

Pus cells are looked for during the microscopic examination 
of feces for parasites and ova. Pus in small amounts usually 
suggests ulceration, but is present in severe enteritis. Large 
amounts of pus recognizable to the naked eye take origin outside 
the tract, either pericaecal abscess or, in women, pelvic abscess. 

In obscure intestinal disorders especially, the feces should be 
examined for parasites and ova. Amoebae are more easily detected 
in scraps of blood-stained mucus in a fresh stool. By passing a 

* An intimate friend, a well known surgeon, was operated upon some years 
ago for what I supposed to be gastric ulcer. He had characteristic pain, hyper- 
chlorhydria, and blood was detected in the stools on every examination during 
several months of observation. No ulcer was found, but the patient made a perfect 
recovery following drainage of the gall-bladder. Later he recalled that his gums 
bled freely after brushing his teeth ! 


rectal tube with a side islet a piece of mucus can usually be 
obtained. Ova and small parasites are easily found in the liquid 
stool following a dose of salts. 

In cases suspected of dysentery, and especially cholera, 
bacteriological examination of the stools is essential. In the last 
few years a number of ill-defined digestive disorders have been 
ascribed to abnormal intestinal flora. This conception rests on a 
very frail scientific basis. The so called chronic intestinal intoxi- 
cation is just as likely due to depression of the de toxica ting func- 
tion of the liver as to an increase of toxins produced. There are 
toxins a-plenty produced as products of normal metabolism. 
The intestinal flora is responsive in considerable degree to the 
character of the diet, protein encourages one type of growth, 
carbohydrate another. Without a suitable food adjustment the 
type of flora can not be changed, with it some change occurs as a 
consequence. Torrey demonstrated some years ago that strains 
of B. acidophylus can be made to grow in the intestine of adult 
man. By regulation of diet after feeding the culture it will per- 
sist at least eight months, I have found. But I have observed 
nothing convincing regarding the therapeutic value of this change 
of intestinal flora. When a neurotic individual, living on a badly 
balanced diet, and complaining of various types of digestive dis- 
order is fed rationally, given rest or occupation, his "mental stream" 
corrected by environment and suggestion, he is apt to improve. 
Implanting a new type of intestinal flora may be a potent means 
of psychic suggestion. 


The cases of "chronic dyspepsia" caused by obscure lesions 
outside the stomach present some of the hardest problems in 
diagnosis. Gall-stones may be present without pain or a charac- 
teristic symptom or sign for years. Flatulence, "sour stomach," 


"bloating," attacks of nausea, are among the commoner symptoms. 
These dyspeptic symptoms are not characteristic but are common 
to all types of chronic gastritis irrespective of cause. The symp- 
toms are induced by secretory and motor disorders of the stomach 
and probably elsewhere in the intestinal tract also. The motor 
disorder is apt to be spasm (of the pylorus) at least in the early 
periods of the disease. Hyper chlorhydria may be present but 
when gastritis has existed for a considerable time there is often 
anacidity. This group of disorders is sometimes referred to as 
" reflex digestive disorders," by which is meant that the digestive 
function is upset secondary to some lesion outside the tract. 

From the data secured by a careful history and routine exami- 
nation it is usually possible to decide that a given case is one of 
disease in the digestive tract proper, or one of reflex disorder. 
If one of reflex causation the problem is to determine the source 
of irritation. In some cases adhesions may induce characteristic 
deformities visible by fluoroscopic examination, but sometimes not. 
Or the fact of an operation in the past may suggest adhesions as 
the probable cause of the disorder. In something less than half 
the cases of cholelithiasis, the diagnosis can be made by x-ray. 
Or again in woman there may be definite evidence of an infection 
in the pelvis, pyosalpinx for example, and then it is a matter for 
speculation whether this is the cause for the digestive disorder 
or whether there is some other. In spite of most conscientious 
attention mistakes are not infrequent, and prognosis beset with 

The commoner diseases causing reflex digestive disorders are 
cholecystitis, localized adhesive peritonitis, tuberculous peritonitis, 
pyosalpinx, chronic appendicitis and nephrolithiasis. The recog- 
nition of any of these may require the most searching examination. 
Cirrhosis of the liver is not a rare cause of chronic gastritis. In 
the earlier stage, before ascites and before the clinical picture is 


complete the diagnosis of cirrhosis is very difficult (Rolleston) . 
Numerous functional tests of the liver have been proposed but 
none has met with general recognition. 

For the diagnosis of the diseases which cause reflex digestive 
symptoms there is in general only the methods already outlined. 
Possibly an exception may be made in cholelithiasis on account 
of the Lyon method. It is yet too soon to express an opinion con- 
cerning the value of this test. This test depends on the fact that a 
solution of magnesium sulphate introduced into the duodenum 
relaxes the sphincter of the bile-duct and as a result there is a 
copious flow of bile. This bile is aspirated through a duodenal 
tube and subjected to test. A duodenal tube is passed in the usual 
way already described. When the tip of the tube is in the duode- 
num as indicated by the color and alkaline reaction of aspirated 
samples, 25 c.c. of a 25 per cent solution of magnesium sulphate is 
injected into the duodenum with a syringe. The patient should 
then lie on his left side and the outer end of the duodenal tube be 
lower than the bed level to favor siphonage. After a quarter 
of an hour if duodenal secretion has not begun to return through 
the tube it can be started by suction with a syringe. The duo- 
denal secretion (i.e. the bile) is examined for pus ceils, crystalline 
material and the number of bacteria present. It is claimed that 
these are all abnormally increased in cases of cholelithiasis. 

The superficial areas of hyperaesthesia vaunted by some in the 
diagnosis of disease of the gall-bladder are not an invariable sign. 
Areas of sensitiveness in the intercostal spaces below the eighth 
rib on the right side are occasionally notable in cases of choleli- 
thiasis, but I have found these tender points in other diseases of 
the digestive tract as well. It is not to be forgotten that in some 
cases the pain of cholelithiasis is referred to the left side and left 
shoulder instead of to the right side and right shoulder as is 
usually the case. 


The essential facts to be determined by physical examination in 
cases of suspected cholecystitis and cholelithiasis are sensitiveness 
over the gall-bladder region, dilatation of the gall-bladder, enlarge- 
ment of the liver or spleen, jaundice, evidences of infection, chills, 
fever, leukocytosis (Charcot's fever). In obstruction of the 
common duct by stone the gall-bladder is dilated in only 15 per 
cent, when the obstruction is due to some other cause, in 85 per 
cent of the cases there is dilatation. The urine of suspected 
cases should be tested frequently for bile. Slight degrees of 
obstruction which do not cause detectable jaundice sometimes 
cause small amounts of bile in the urine for a brief time. 


Various diseases cause ascites, the commonest being cardio- 
renal disease, tuberculous peritonitis, hepatic cirrhosis and carci- 
noma. Ascites may be well simulated by large ovarian cysts 
and more than once a distended bladder has been aspirated under 
a misapprehension. 

The recognition of considerable amounts of fluid in the peri- 
toneal cavity is not usually difficult. The shape of the abdomen 
as the patient lies on his back in bed; the percussion dulness in 
the flanks with tympany near the mid-line and in the upper 
area of the abdomen; often movable dulness and a fluid wave 
are all easily elicited signs. Ovarian cysts are sometimes mistaken 
for ascites. The significant facts for differentiation of the two 
conditions are that cysts fill the lower part of the abdomen 
or one side of the abdomen, leaving the flanks tympanitic, while 
movable dulness can not often be elicited, and a pedicle can usually 
be determined by vaginal examination (see gynecological exam- 
ination). Confusion is most apt to occur when the diagnosis is 
between ovarian cyst and ovarian tumor with ascites. Adeno- 
cystoma of the ovary may induce ascites as the first symptom. 


Early recognition is important since the implantations on the 
peritoneum may disappear following removal of the primary 

A small amount of fluid in the peritoneal cavity is sometimes 
the significant fact in diagnosis. When the amount is less than 
a liter the signs are usually indefinite and careful attention to 
details is essential to recognition. The contour of the abdomen 
is not changed, and movable dulness can not be made out defi- 
nitely. If the patient be placed in the knee-elbow position the 
fluid gravitates to the dependent part of the abdomen and gives 
a dull note on percussion. With the patient in this position 
a fluid wave can sometimes be obtained. Placing the fingers 
of one hand on one side of the abdomen and giving a short quick 
tap to the opposite side, a wave-impulse is felt as a shock by the 
palpating hand. If the patient is fat or the abdominal wall 
relaxed an assistant should hold the edge of his hand in the mid- 
line of the abdomen to prevent the loose tissues from carrying 
a wave. At times all signs leave one in the dark and recourse 
must be made to exploratory puncture. Puncture is safe and can 
be made painless. A trocar and cannula of small calibre adapted 
to a syringe is preferable. Puncture is made two inches above 
the symphysis pubis. When the amount of fluid is small the 
needle should be directed toward the pelvis and the patient 
lean well forward or be in the knee-elbow position. It is important 
that the bladder be empty, and if there be any doubt the patient 
should be catheterized. 

Ascitic fluid varies in character in different diseases. The 
significant facts are determined by examination of the specific 
gravity, microscopic study of cells (and in some cases differen- 
tial leukocyte count), bacterial cultures in acute inflammations, or 
guinea-pig inoculation in cases of suspected tuberculous peritonitis. 
Haemorrhagic effusions occur in cancer, tuberculous peritonitis 


and (rarely) cirrhosis. In cancer of the peritoneum quite charac- 
teristic cells may be found in the exudate. 

A special technique is required to palpate organs or tumor 
masses in case of ascites. This method is known as "dipping." 
The pads of the fingers are placed on the abdomen and then 
by a quick push the abdominal wall is depressed. By this method 
an enlarged liver is easily felt and a tumor mass can usually be 
outlined and localized.* 

Effusions into the peritoneal cavity in early life suggest 
first tuberculous peritonitis; past middle life, cardio-renal disease, 
neoplasm and cirrhosis. 


Severe abdominal pain of sudden onset, associated with nausea, 
sometimes vomiting and collapse are symptoms suggesting acute 
intra-abdominal disease, most frequently appendicitis. When in 
addition to these symptoms there is sensitiveness and muscle 
spasm or muscle rigidity, fever and leukocytosis, it is easily 
forgotten that the disease may be in the thoracic cavity. Few 
surgeons indeed have not at some time mistaken pneumonia for 
acute appendicitis. I have made the mistake even when endeavor- 
ing to avoid it. The clinical picture is generally designated by 
surgeons as acute surgical abdomen. The symptoms and signs 
of acute peritonitis often indicate exploration even though the 
exact nature of the disorder can not be determined. Of abdominal 
conditions which may cause this picture, the more common are 
acute appendicitis, perforation of peptic ulcer, rupture of bowel 

* Curiosity is seldom merely idle. About ten years ago I was entrusted with 
the care of a patient who was believed to have carcinoma of the liver. On first 
impression one would concur in the probability, the patient was so emaciated, 
deeply jaundiced and utterly hopeless. There was marked ascites and nothing 
could be felt in the abdomen. Curiosity to feel dictated aspiration. The patient 
began to improve as by magic. Nothing was felt in the abdomen and the man is 
apparently in perfect health today. Diagnosis (?) 


due to trauma, acute pancreatitis, rupture of a diseased gall 
bladder and intestinal obstruction. The first evidences of gastric 
or duodenal ulcer in some cases are symptoms of perforation. Of 
twenty-six cases operated upon for perforation I found eleven only 
who gave a history of any digestive disorder whatsoever. 

The physical signs of acute surgical abdomen are the signs of 
early acute peritonitis. The patient appears not only severely 
ill but distressed and anxious. The face may be ashen and drawn 
from pain, and perspiration visible on the forehead. He assumes 
a posture designed to relax the abdomen, either on the back with 
knees drawn up, or on the side with the head and knees drawn 
together. Respirations are entirely of the costal type and labored 
in short jerky movements. Palpation of the abdomen reveals 
generalized sensitiveness which may be most marked in some area 
dependent on the lesion. There is a general increased muscle tone 
with local spasm on pressure or the whole abdomen may show a 
board-like rigidity. Fever may be present. In cases of perf oration, 
if seen early, the temperature is subnormal and the pulse rapid and 
weak. The pulse is variable. Unless there be a clear history of the 
mode of development of the disease or some circumstance to aid, the 
diagnosis depends largely on exclusion. 

Both pulmonary and cardiac disease may cause abdominal 
pain. Abdominal pain with pneumonia in children is a prover- 
bial source of confusion. In the first few hours before abnormal 
signs can be detected in the lungs diagnosis may be impossi- 
ble. Or there may be undoubted pneumonic consolidation 
and then the signs of peritonitis attributed to the pneumonia. 
In a case of pneumonia with secondary pneumococcic peri- 
tonitis I made this mistake. In a similar dilemma again I would 
tap the abdomen and examine the fluid recovered. 

Two cardiac disorders especially are accountable for mistakes 
in the diagnosis of abdominal pain — coronary thrombosis and 


acute pericarditis. Cardiac failure of any type induces passive 
congestion of the liver, and pain, but this condition can usually be 
detected without much difficulty. Infarction of the heart due to 
coronary thrombosis may cause severe abdominal pain, usually 
in the upper half of the abdomen, with vomiting and collapse. 
There may be fever and leukocytosis. Cases have been operated 
upon for gall-stone. Old healed infarctions found at autopsy are 
evidence that patients may have these attacks and survive (J. B. 
Herrick). The important facts for the recognition of these 
attacks when they simulate an abdominal disease are (a) history 
of previous attacks or of cardiac pain, (b) enlargement of the heart, 
(c) distant or weak heart sounds, and particularly diminished 
intensity of the first sound, (d) small thready pulse either rapid 
or abnormally slow. The disorder is usually found in men over 
40 years of age. 

Acute pericarditis is not a frequent cause of abdominal pain of 
a character likely to lead to error in diagnosis. Errors which 
have come to my attention were due either to omission of examina- 
tion of the heart or ignorance of the fact that signs of pericarditis 
may be found only posteriorly. 


The patient is given no breakfast. The metal tip of the tube 
is lubricated with glycerine and the patient then swallows the tube 
till the " pyloric" mark on the tube meets the teeth. A specimen 
of the stomach contents is at once aspirated with a glass aspirating 
syringe and the stomach lavaged three or four times with water. 
The patient next swallows the tube to the " duodenal" mark. He 
is then placed on his right side with the hips elevated on pillows 
higher than the shoulders. This position must be kept until the 
tube is in the duodenum when it is no longer necessary. Enough 


water is now injected into the tube to start siphonage and the 
collecting end of the tube is placed in a bottle or jar well below 
the level of the patient so as to facilitate siphonage. The syringe 
should be used for aspiration only when siphonage fails or the 
tube becomes plugged. 

One knows when the tube enters the duodenum by (a) the 
returning liquid becoming a clear, golden yellow and much more 
viscid and ropy, (b) the reaction changing from acid to alkaline. 
To verify the fact that the tube is in the duodenum pull the tube 
gently and elicit a resistance, the so-called "duodenal tug." Or 
have the patient drink a couple ounces of milk and then aspirate 
at once with the syringe. If the bucket is in the stomach the 
milk will be recovered. Barium emulsion may be injected into 
the tube and the abdomen fluoroscoped which will localize the 
tube exactly. Normally the tube should reach the duodenum in 
twenty or thirty minutes. If there is delay sometimes a few 
ounces of water will stimulate peristalsis or the tube may be 
slightly withdrawn and swallowed further. 

When the tube is in the duodenum the specimens are collected 
as follows: First collect a specimen from the duodenum, then 
instill with the syringe 60 c.c. of a 25% solution of magnesium 
sulphate. Shut the tube for a moment and then let it drain 
out. For the Lyon's test start the collection of specimen "A" 
as soon as bile begins to flow. Specimens "A," "B," and "C" 
are collected in separate bottles. The separation of the speci- 
mens is determined by the character of the bile noted through 
a glass "window" in the tube. There seems much uncertainty 
even in the minds of competent gastroenterologists as to just when 
specimen " A " or " B " is complete and the next begun. 

According to Lyon Bile "A" is from the common bile duct. 
It is of golden yellow color, transparent, and of medium viscosity 
and amounts to 5 to 10 c.c. 


Bile "B" is dark golden yellow and more viscid and amounts 
to 30 to 160 c.c. 

Bile "C" is light, transparent, lemon yellow in color, thinner 
and more limpid. The flow is intermittent and of 10 to 60 c.c. 

"B" bile comes from gall-bladder in Lyon's opinion, and "C" 
bile from the ducts and liver. 

The bile is sometimes turbid, due to admixture of gastric juice 
discharged into the duodenum during the test. 

The laboratory examination on the samples is as follows: 
the contents of the fasting stomach is tested for free and total 
acidity and the sediment examined microscopically for comparison 
with the duodenal samples. The duodenal sample and specimens 
"A," "B," and "C" are examined for (1) amount, (2) specific 
gravity, (3) reaction, (4) color, (5) turbidity, (6) precipitate, 
(7) centrifugalize (5 c.c.) to note proportion of sediment. Ex- 
amine sediment microscopically for pus cells, bile stained epithe- 
lium, mucous material and bacteria. Look especially for 
cholesterin and other crystals. (8) Rub some of the sediment 
between the fingers to determine whether it is gritty. 

The significance of bacteriological study of the samples is at 
present so dubious that it is not worth while recording the 


The commoner symptoms of which the patient complains 
are tickling or itching sensation in the meatus, discharge, pain, 
frequency of urination, painful urination, difficult voiding or 
dribbling, changes in the appearance of the urine (bloody, smoky 
or cloudy) . Some of these symptoms and their order in develop- 
ment may suggest the nature of the disease. But a simple routine 
examination should be made in every case and would prevent 
many common mistakes. When there is pus in the urine, for 
example, cystitis is often wrongly diagnosed. Passage of the 
urine into two beakers with pus only in the first, the second 
clear, is sufficient to show that the pus does not come from the 
bladder but anterior to it. And when pus from fresh urine 
shows no bacteria after staining with methylene blue, a pyo- 
genic infection is excluded. The case is probably one of tuber- 
culosis or stone. The routine examination includes examination 
of the contents of the scrotum, testis, epididymis, vas deferens, 
prostate, seminal vesicles, bladder, ureters and kidneys. 

The testes, epididymis and vas deferens are palpated to detect 
nodules or areas of induration. Small hydroceles may be of 
significance if of recent development and note is to be taken 
also of thickenings or nodules in the spermatic cords. Epididy- 
mitis, prostatitis and vesiculitis occur in over 70% of cases of 
renal tuberculosis in men. Luetic epididymitis, unlike that of 
tuberculosis, is not sensitive to pressure, and has a characteristic 
clam shell contour with the testis in the center. 

The size, position and degree of sensitiveness of a kidney 

is important in many cases. In fat patients the examination 



is difficult. When the kidney can not be clearly felt, some idea of 
degrees of sensitiveness can sometimes be secured by "dipping." 
One hand is placed in the costovertebral angle and the other 
over the kidney on the anterior abdominal wall. The two 
hands are to be gradually approximated. Then by bending the 
fingers of the posterior hand, while the patient inspires, a quick 
push is made which throws the kidney against the anterior 
palpating hand. 

Normal ureters are not palpable and the enlargement and 
thickening due to disease are detectable only in thin subjects. 
Sensitiveness along their course can be determined even when the 
ureters are not felt. 

The prostatic examination is done most conveniently last. 
(See Rectal Examination.) 

Prostatic secretion, secured by prostatic massage, is examined 
microscopically, especially for pus and blood cells. Even inter- 
nists devoted to the theory of focal infection often forget the 
prostate as a possible focus of infection. 

Examination of a specimen of urine for pus or blood gives 
only the information that the sample is normal or abnormal. 
If abnormal it is necessary to know where in the urinary tract the 
lesion exists — kidney, bladder, or urethra. Interrupting urina- 
tion, having the patient empty the bladder into two or three 
glasses, is a very valuable and simple procedure. Blood or pus 
from the bladder or kidney will be uniformly mixed in the urine 
and will show in all three samples. Pus from the urethra is 
washed out by the first urine voided and will show only in the first 
sample. Blood from the posterior urethra, however, may appear 
only in the third sample — a few drops at the end of urination. 

Pus in the urine should be invariably examined for bacteria. 

Culture is not necessary in the first instance. The material 

secured by centrifugalizing the urine is spread on a slide, fixed 


and stained with methylene blue. In infections of the tract 
there are usually numerous bacteria. Pus which shows no bac- 
teria suggests strongly that the case is one of tuberculosis, stone, 
or possibly tumor. 

Tuberculosis of the kidney often escapes recognition at the 
most favorable time for surgical treatment.* Careful investiga- 
tion of every case of haematuria and pyuria would save lives. If 
the specimen contains no bacteria by the method outlined above, 
the sediment is to be stained for tubercle bacilli. If the meatus 
be properly cleansed and the second glass sample be used, there 
will be no confusion from smegma bacilli and decolorization or 
special fixation will be unnecessary. If the cause for the pus or 
blood is not readily discovered, guinea pigs should be inoculated 
with the urine and a tuberculin test done on the patient. About 
one third of the cases of renal tuberculosis show signs of pulmon- 
ary tuberculosis. Frequency of urination, especially nocturia, is 
the initial symptom in 85 per cent, of the cases of renal tuberculosis. 
Haematuria occurs in about 40 per cent. It may be the only 

Haematuria, without other symptoms, may be due to tumor of 
the bladder, especially papilloma. Diagnosis is usually clear on 
cystoscopic examination. 

Vesical symptoms — frequency, burning, pain, haematuria — 
in a young individual, without evidence of gonorrhoea, stone, 
stricture or prostatic disease, is usually due to tuberculosis, 
probably of renal origin. If tubercle bacilli are not demonstrable 
in the urine the examination is not complete without cystoscopy, 
which often reveals characteristic lesions to the trained observer. 
X-ray may give useful evidence in about 25 per cent, of the cases, 
usually advanced cases. Pyelography is occasionally of help. 

* There is still a notion that renal tuberculosis "heals." It is doubtful if there 
be a single case of renal tuberculosis recorded where cure resulted from purely 
medical treatment. 


Diverticula of the bladder are sometimes the cause of severe 
symptoms of cystitis. These symptoms are due to the diverticu- 
lum not emptying. Diagnosis is made by cystoscopy. 

Examination with metal sounds and metal catheters requires 
a definite technique and the procedure should be attempted only 
by the instructed. In an emergency it is to be remembered that 
no force is needed to pass a metal catheter. Force may cause 
serious injury. 

The use of soft rubber catheters is safe and devoid of danger if 
surgical cleanliness be observed. Catheterization is indicated 
when there is reason to suspect that the bladder does not com- 
pletely empty itself on voiding. This is especially true in prosta- 
tism and cases of prostatic enlargement or induration from any 
cause. In order to form an opinion in many cases of obstruction 
it is necessary to know the amount of residual urine. Deter- 
mination of residual urine is a part of the necessary routine 
examination in every case of prostatism. 


The position of the patient for rectal examination should 
permit complete relaxation and, on this account, the left lateral 
or Sims position is usually preferred by internists. It is the best 
position in which to begin the examination. When recto-ab- 
dominal palpation becomes desirable the lithotomy position is 

For the examination the use of rubber gloves is highly to be 
recommended. Some prefer finger cots, winding a piece of gauze 
around the proximal end of the finger and hand. 

The examination should be begun by inspection of the area 
about the anus for the detection of the openings of fistulous tracts 
and for abscesses. The external or anal fistula most commonly 
appears as a papule from which a drop of pus can be made to 
exude by pressure with the finger within the rectum. Sometimes 
a fistulous tract can be felt as a cord-like induration extending 
from the anal canal to the external opening. Peri-anal or ischio- 
rectal abscesses may appear outside of the margin of the anus as a 
reddish swelling. The size of the abscess, its nature and extent can 
be determined by bimanual examination with one finger within the 

When the finger enters the rectum it will point anteriorly until 

the sphincters are passed. The ringer is then directed upward and 

posteriorly. At first the examiner should endeavor to detect any 

change from the normal elastic, smooth feeling of the rectal mucosa. 

Areas of induration, elevations or depressions are to be noted. 

The usual disease conditions of the rectum are found within the 

first two inches from the anus. 




In case visual inspection of the rectum is desired, one has 
recourse to the proctoscope. A fair inspection can be secured 
without aid of instruments. In order to do this it is necessary to 
have the patient in the knee-chest position, so that the atmospheric 
pressure will balloon the rectum. First insert one index finger up 
to the second joint, then the other. This procedure should be 

Fig. 40. — Rectal shelf. A sign of value in the diagnosis of malignant and inflamma- 
tory disease within the abdomen. 

done slowly and gently. When both ringers are in the desired 
position they are gently separated. The rectum promptly bal- 
loons from air pressure and can be examined by reflected light or 
an electric head light. By this method one can see, however, only 
as far as the rectal valves or folds of Houston. 


For examination higher up, as in cases of amoebic ulcers for 
example, the sigmoidoscope is necessary. 

The most important conditions to be looked for in the lower 
portion of the rectum are stricture, due usually to lues or tuberculo- 
sis and carcinoma. The marked induration of carcinoma is not 
simulated by any other condition. Occasionally the indurated 
area may present a depression due to ulceration. 

The examination of the rectum is not complete without 
palpation of the prostate. The normal prostate is felt as heart 
shaped, with the apex joining the membranous urethra. The 
lateral lobes are soft and elastic and their borders rather indefinite. 
The normal prostate does not project into the rectum, the lobes 
being flat rather than bulging. There is a considerable variation 
in the feel of normal prostates, some being more tender than others, 
and more elastic. There are also differences in the size of the 
gland. Adjacent to the gland small nodules may often be felt 
which are either enlarged lymph glands or phleboliths. The 
normal prostate is flaccid and relatively insensitive and there are 
no areas of induration. Rounded tense lobes suggest either hyper- 
trophy or inflammation. Sensitive tense lobes suggest infection. 
Indurations within the lobes may be due to inflammatory foci, 
tuberculosis, neoplasms, or prostatic calculi. If the induration 
with nodules extends from the prostate into the base of the bladder 
the condition is in all probability a neoplasm. The normal semi- 
nal vesicles are impalpable. Inflamed seminal vesicles may be 
felt just above the prostate laterally and extending upward. 

The common conditions which give rise to enlarged prostate 
are simple adenoma or prostatism, neoplasm and prostatic calculus 
and abscess. Carcinoma is to be suspected in men over fifty, 
who present symptoms of, (I) simple prostatism, (II) sciatic and 
pelvic pains, (III) metastatic bone involvement and loss of weight. 
The chief points in the examination of the prostate for carcinoma 


are nodules in the prostate, especially at the apex, and pathogno- 
monic if extending into the seminal vessels and base of the bladder. 
These nodules can be better felt with a sound in the urethra. 
Nodules in the apex of the prostate in youth are usually due to 


A gynecological or pelvic examination consists of a vaginal 
examination, followed by a combined or bimanual examination. 
In the vaginal examination the external genitalia are inspected 
and a digital exploration of the vagina done, followed, if possible, 
by inspection of vagina and cervix through a speculum. In 
the bimanual examination the pelvic organs are palpated between 
the tips of the fingers of the two hands — the finger or fingers 
of one hand being inserted into the vagina or rectum and those 
of the other hand pressing on the abdominal wall. 

In the preliminary vaginal examination one notes the presence 
and character of vaginal or urethral discharges, the condition 
of Bartholin's glands, the presence of condylomata, urethral 
caruncle, mucous patches, ulcerations, excoriations or atrophies. 
The patient is asked to strain or bear down and prolapse of the 
vaginal walls or of the uterus is detected. With the ringer in the 
vagina, the examiner may determine the condition of the perineum 
and urethra. He also may feel foreign bodies and palpate the 
cervix. The position of the uterus may be determined and much 
information about pelvic masses may be obtained by simple 
digital vaginal examination. Inspection through a speculum 
is necessary to detect and observe fistulous openings, and will 
often reveal a cervical erosion or polyp that may have escaped 
palpation. Cervical polyp is notoriously difficult to feel, espe- 
cially if gloves are worn. 

The greatest difficulty commonly experienced in the combined 

examination is due to the tension of the abdominal muscles. 

In order to bring about a relaxation of these muscles it is necessary 



for the patient to be in such a position that the lower border of 
the thorax and the upper border of the pelvis are approximated 
as much as possible. This position is secured by flexion of the 
trunk in the anterior plane, the shoulders and head being elevated. 
Many examining tables are designed to meet this requirement, 
but the position can be satisfactorily secured on a bed or couch. 
The other important point in securing proper position for the 
examination of the pelvic organs is the position of the legs; 
the thighs should be flexed at the hip joint and abducted. The 
closer the thighs are brought to the body the greater will be 
the elevation of the pelvis and the consequent relaxation of 
the abdominal walls. Gentleness in examination is essential, for 
if pain is produced the patient will contract the abdominal muscles 
and prevent the combined palpation or make it very difficult. 

A glove should be worn on the hand used in the vaginal 
examination. It may interfere slightly at first with palpation 
but one soon becomes accustomed to it. A well lubricated 
gloved finger makes the examination as easy as possible for the 
patient and guards both her and the examiner against infection. 
In case of threatened or incomplete abortion, rigid aseptic pre- 
cautions should be observed as in an obstetrical examination. 

When the examination is conducted with the patient lying 
down on a couch or bed, the examiner will find it most convenient 
to sit upon the bed at the patient's left. It is better to have the 
patient on a table in a good light. The examiner then stands 
at ease between the patient's thighs. Most gynecologists employ 
the left hand for the internal examination, using the right for 
abdominal palpation. They have trained their left hand to 
vaginal palpation, so as to have the right hand for use in handling 
instruments, such as the speculum, applicator, dressing forceps or 
probe, and for inserting tampons or packing and for various 
other manoeuvers that a right handed person can do best with 


the right hand. The reverse would be true if the examiner 
were left handed. Some men change hands in the bimanual 
examination, using the left hand vaginally when palpating the 
left side of the pelvis and vice versa. 

One should always see to it that the patient empty her bladder 
immediately before a bimanual examination is attempted. The 
rectum, too, should have been emptied before. The patient, 
then, having been freed of any clothing that would constrict 
the abdominal wall, especially corsets, and placed in the position 
described, the examiner seats himself at the patient's left or 
stands between her thighs if she is on a table. The left index 
ringer is then introduced into the vagina, the thumb being pressed 
firmly against the perineum. Next the crooked middle ringer 
is slowly introduced; the hand is then rotated so that the volar 
surfaces of the ringers are directed against the anterior vaginal 
wall. It is preferable to use two ringers, if possible, to obtain 
the advantage of the extra length of the middle ringer, and besides, 
by spreading the ringers apart an idea of dimension can be secured. 
When the internal hand is in the proper position, the external 
hand is placed upon the abdominal wall, with the ringer tips 
directed backward toward the umbilicus. 

It is better to observe a definite order in conducting the exami- 
nation of the pelvic genitalia: first is noted the condition of the 
vaginal canal — the tone of its walls and the condition of the 
mucous membrane. Next the cervix is felt — its direction noted 
as also its size and consistency, as well as the condition of the 
external os. Finally the fornices are palpated with the vaginal 
ringer noting the consistency of the tissues — presence of masses 
and the degree of mobility in all directions. 

The uterus itself is then investigated. Holding the cervix 
between two ringers, the uterus can be elevated so that pressure 
through the abdominal wall by the external hand brings it into 


position to be palpated between the external and internal hand. 
The chief points to be noted are — (a) the position of the uterus, (b) 
its mobility and size, and (c) whether there are any irregularities 
upon the surface. After examining the uterus, the ovary, tube, 
and parametrium on the two sides are to be palpated. 

In the diagnosis of the various possible pelvic disorders in 
women the greatest responsibility is involved in the case of cancer. 
When there are suspicious symptoms as, for example, serosanguine- 
ous discharge, pelvic examination is obligatory. The diagnosis 
of cancer rests in the main upon a demonstration of neoplasm and 
degeneration. Neoplasm is indicated by proliferation on the 
surface or infiltration. Friability of a tissue is suggestive of 

In examining the vaginal portion of the uterus, attention is 
given chiefly to changes in the consistency of the tissue, prolifera- 
tion of tissue and ulceration. When the palpating ringer finds 
indication of proliferation or degeneration, visual inspection with 
the speculum should be made. Naturally, because the tissue is 
more accessible, diagnosis in the vaginal portion of the uterus 
offers the least difficulty. A rough tumor in this region, which 
breaks up with pressure of the finger, is probably cancer. If 
the carcinoma is flat any proliferation beyond the level of the 
mucous membrane is suspicious. A cartilaginous consistency of 
tissue or change in the shape of the cervix is suggestive. When 
with these conditions there is also ulceration, doubt disappears. 
Carcinomatous ulceration of the vaginal portion of the uterus is 
characterized by excavations with uneven, rough, ragged walls. 
Only two diseases can be confused with this type of ulceration, 
syphilis and tuberculosis, the latter of which is rare. Carcinoma 
of the cervix may produce localized induration which at times 
is difficult to differentiate from interstitial fibroma. In short, any 
indurated area about the external os that bleeds easily on contact 


should be looked upon with suspicion, and a piece should be taken 
for microscopical examination. Cancer in the cervical canal 
often gives the feel of a button buried in the body of the cervix. 
There may not be bleeding. In these cases the canal should be 
curetted to obtain tissue for examination. 

In the earlier stages of the disease carcinoma of the body of the 
uterus may give rise to no sign detectable by manual examination. 
The earliest detectable sign is a change in the consistency of the 
uterus resulting from infiltration. Definite diagnosis by digital 
examination can be made only when the invasion has involved 
the surrounding uterine tissue. Diagnosis at the early stage 
most favorable for operation is made from microscopical section. 
Endometritis and degenerating sub-mucus fibroids may give rise 
to similar clinical symptoms, and alteration of the consistency of 
uterine tissue is produced by interstitial myomas and fibromas. 
Therefore the diagnosis of cancer at the time when surgical inter- 
vention is most promising of cure, rests often on microscopic study 
of tissue secured by curretage. When the patient's age and symp- 
toms suggest cancer, delay for lack of definite signs imperils life. 

The diagnosis of uterine myomata depends almost exclusively 
upon the results of palpation. The chief points for consideration 
are the shape of the tumor mass, its consistency and the demon- 
stration of its connection with the uterus : a rounded, hard tumor 
mass definitely connected with the uterine wall is probably a 
myoma. Small interstitial or sub-mucus myomata can only be 
suspected as a result of examination. Changes in the consistency 
of myomata are produced by (a) menstruation, where the vascu- 
larity induces a softening of the myoma, (b) pregnancy, (c) 
degeneration and suppuration. 

Palpation of the appendages aids in the diagnosis of a myoma of 
the uterus in helping to recognize the seat of the tumor. It is 
important to trace the course of the round ligaments. These are 


searched for directly above the horizontal ramus of the pubic 
bone by depressing the abdominal wall with the external hand. If 
a firm cord is felt in this area its course should be traced to the 
tumor. If the round ligament joins the tumor, it shows that the 
mass is in the uterus, and, in addition, it locates the position of 
the fundus. Likewise the position of the ovaries may be affected 
by the presence of myoma ta. 

Practically differential diagnosis lies between myomata and 
ovarian tumors. Occasionally old inflammatory conditions of the 
tubes and ovaries are mistaken for nbromyomata. 

The Ovaries. — The diagnosis of ovarian tumors rests almost 
exclusively upon the palpatory findings. The history in most 
cases is not of great importance and frequently is misleading. The 
general rule that cystic tumors are ovarian in origin in contrast 
to solid tumors which are so frequently myomata, is not, however, 
a safe rule. Myomata may be soft and seem fluctuating, solid 
tumors are not rare, cysts may have thick capsules and seem hard 
to the touch, i.e., dermoids. The consistency of a tumor is very 
important but hard to estimate, especially if the patient has thick 
abdominal walls. There are two points essential in diagnosis, the 
consistency of the tumor and the demonstration of the pedicle. 
The best method of determining the consistency is by grasping 
the tumor between the internal and external hand at two opposite 
points and then compressing with short, pushing movements. 
Frequently this examination is best conducted through the rectum. 
The demonstration of the pedicle may be easy or may be very 
difficult. Mistakes are frequently made. One wishes to know 
whether the pedicle is thin or thick and whether inserted in the 
fundus or not. It is important if the tube can be demonstrated 
as part of the pedicle. 

The examination is most difficult when the uterus is behind the 
tumor. To meet the various difficulties the method of Schultze 


and Hegar is often resorted to. The patient must be anesthetized. 
This method consists in grasping the vaginal portion of the uterus 
with a double tenaculum and drawing the uterus down. This 
serves to put traction upon the pedicle. Internal examination 
under these conditions must be made by rectum. The external 
ringers are passed to and fro between the cornu of the uterus and 
the tumor in a direction perpendicular to the course of the pedicle. 

The conditions which chiefly confuse the diagnosis of tumors of 
the ovary are pedunculated myomata, encapsulated peritoneal 
exudates, echinococcus cysts and extra-uterine pregnancy. Large 
ovarian cysts are frequently mistaken for ascites. Enlarged 
spleen has been mistaken for ovarian cyst. The most serious 
error is to mistake a carcinoma of the lower sigmoid for an ovarian 
cyst. It may lie in the pelvis in the location of the ovary. 

Tubes. — The normal tube is palpable only under favorable 
conditions. Diseased tubes, on the other hand, on account of 
the thickening of their walls, may be quite easily felt. The 
external hand should be pressed firmly against the internal fingers 
so that the palpating fingers become approximated alongside the 
uterus; they are then to be moved up and down perpendicular to 
the course of the tube. On account of tenderness the tube is not 
readily felt in acute salpingitis. There is palpable only an indefi- 
nite, soft consistency, with notable tenderness. In purulent 
salpingitis the tube may be as large as the finger and identified 
by its increased consistency and tortuous course. 

When there is much inflammation it may be necessary to use 
a general anesthetic for the examination. Hydrosalpinx is 
characterized by a cystic tumor, of sausage shape and irregular 

The diagnosis of these conditions depends upon the demonstra- 
tion of a tumor alongside the uterus and separated from it. The 
tubal origin of the tumor is indicated by a thick cord running from 


the cornu of the uterus to the tumor. The conditions commonly 
mistaken for diseases of the tubes are ovarian tumors, subserous 
myomata and tubal pregnancy. Neoplasms of the tubes are rare. 
The diseases of the female genital organs which give rise to 
tumor masses are, in order of frequency: salpingitis, uterine 
nbro-myoma, ovarian cyst, tubal pregnancy, solid tumors of the 
ovary, cysts of the broad ligament, neoplasm of the uterus. 


I. Clinical History and Outline for Examination. 
II. Eyes. 

i. Vision. 

2. Nerves of extrinsic eye muscles. 

(a) Diplopia; (b) conjugate movements. 

3. Ophthalmoscopy. 

4. Visual fields. 

III. Cranial Nerves. 

The fifth and seventh pair, 

The acoustic nerve. 

The cochlear division. 

Vestibular apparatus. 

Ninth, tenth, eleventh and twelfth nerves. 

IV. The Motor System. 

Power, tone, coordination. 
Tests of muscle power. 
Tests for coordination. 
V. Reflexes. 

Deep reflexes. 
Superficial reflexes. 
VI. Testing Sensation. 
VII. Convulsions and Coma. 
VIII. Lumbar Puncture. 


The diagnosis in neurology is formulated out of signs and 

symptoms which often seem less connected and hence more occult 

than in other departments of medicine. For this reason system 

in examinations is indispensable. In taking the history the 

general plan employed in all medical histories is not abandoned. 

On the contrary it is only supplemented by certain details. One 

should let the patient tell his own story in his own way; since this 

aids frequently in forming an estimation of the patient's mental 

state. The history so secured may require analysis and further 

questioning to elucidate obscure symptoms. First it is necessary 



to understand the mode of onset of the disorder; whether the illness 
started suddenly as in vascular lesions, gradually as in degenera- 
tions and tumors, or whether there were remissions in the progress 
of the disease. Some symptoms are of greater importance than 
others and may require to be brought out cautiously by tactful 
question. Sometimes important symptoms are forgotten and a 
question refreshes memory. Definite information is desired con- 
cerning (a) headaches, and, if present, their character and location; 
(b) digestive upset; (c) visual disorders; (d) diplopia (always 
important) ; (e) vertigo, constant or only in the dark, tendency to 
fall in a certain direction; (f) pain, " girdle" or "lightning," root 
pain, etc.; (g) fainting spells or other disorders of consciousness; 
(h) convulsions (best called " attacks") tonic or clonic, general or 
local; (i) disturbed sleep ; (j) disorders of micturition and defecation. 

The largest single groups of nervous disorders are traceable to 
syphilitic infections, hence the importance of inquiries in this 

During the conversation necessary to the securing of a clinical 
history the acute physician is able to gain considerable insight 
into the mentality of the patient. He can best form his impres- 
sion of the patient's mentality under the headings: attention, 
memory, orientation, emotional state, mental grasp, stream of 
thought, judgment and insight, hallucinations or delusions. 
The following scheme is useful in preventing omissions in 

Psychic State. Attention. Emotional state. Mentality. 
Delirium. Coma. Drowsiness. 

Nervous System. 
Cranial Nerves: 

I. Olfactory sense. 
II. Acuity. 


III, IV, VI. Pupil: reactions; regularity of outline. 
Ocular movements. 
V. Motor. 
VII. Motor. 

VIII. Cochlear; acuity; tinnitus; vestibular. 
IX, X, XI, XII. Movements of tongue. 

Motor System: Head attitude. 

Upper extremities: 
Power at each joint. 

Muscular nutrition. 
Adventitious movements: 

Fibrillary twitching. 

Ataxia and coordination, including deviation test. 
Trunk: Power of abdominal wall muscles. 

Umbilical excursion. 
Lower extremities: As in upper extremities with addition of station and gait. 
Reflexes : 

Superficial: Corneal, palatal, epigastric, abdominal, bulbo-cavernosus, plantar. 
Deep: Jaw, wrist, elbow, knee and ankle. 

Ankle and patellar clonus. 
Organic: Micturition, retention, retention with overflow, incontinence. 
Periodic automatic incontinence. 
Defecation control. Priapism. 

Sexual potency. Urethral and anal sensations during sphincter 
Sensory System: Subjective pain, direction of radiation, character, frequency. 
Paraesthesia. Headache, tingling. 

Sensibility to touch, pain, deep pressure pain, sense of position 
at joints and temperature. Vibration sense. Stereognosis. 
Trophic functions: Skin, bullae, herpes, bedsores, perforating ulcers. 
Glossy skin, erythema. 



Serious impairment of vision will have been detected by the 
patient, but it may be doubtful whether he is able to tell light from 
darkness. His ability to do this is tested by darkening the room 
and then by means of a mirror or electric torch throwing light on 
the eye to be tested, asking the patient to tell when it is light and 
when dark. 

When the impairment is of a less marked degree recourse may 
be found in counting fingers. Place the patient with his back to 
the light while the examiner faces the patient and holds up a vary- 
ing number of fingers asking the patient to name the number. 

Slight degrees of defects in vision (usually due to refraction 

errors) are easily detected and measured by using Snellen's types. 
These are letters of different sizes arranged on a card, each size 
of letter is normally legible at a definite distance, the largest at 
60 meters and the smallest at 6 meters. The type card should be 
placed in a good light on a level with the patient's eyes, at a 
distance of 6 meters (20 feet) from him. The patient then reads 
the letters from above down. In recording his visual acuity the 
following formula is used : 

V= D 
wherein v = visual acuity, d = the distance of the eye from the 
type; D = normal distance at which the type should be read. 
If he read the smallest type at 6 meters, v = % = normal ; if only 
the largest type be read, v = %q , or }{q normal vision. 


The pupils are observed in respect to size, shape, and mobility. 
There is a wide variation in the size of the pupil in health. Pupils 
which are widely dilated are often an indication of exhaustion or 
nervous instability. Inequality in the size of the pupils is found 


in about 10 per cent, of healthy subjects. When inequality is 
noted it is sometimes difficult to determine which one is normal. 
Usually the more mobile pupil is the normal. Marked inequality 
of pupils suggests organic disease. Abnormal contraction of the 
pupils, myosis, occurs in opium poisoning, tabes and pontine 
haemorrhage. It may be due also to iritis. 

Irregularities in the shape of the pupil are the result of 
adhesions of the iris to the lens or of old iritis. Not infrequently 
these irregularities are a sign of cerebrospinal syphilis. 

The mobility of the pupil is tested for the reaction to light, to 
accommodation, convergence, and the cilio-spinal reflex. 

In testing the light reflex a bright light is required and it is 
necessary to be sure that the patient relaxes his accommodation. 
One may have the patient look out a window, or one may use a 
small electric torch. Cover the eye with the hand for thirty 
seconds, then withdraw the hand and observe whether the pupil 
contracts immediately as it should, is sluggish in contraction, or 
immobile. Next shade one eye while the other is exposed to light 
and observe whether the pupil of the shaded eye contracts or 
dilates depending on the strength of the light. This is the con- 
sensual reflex and its loss is an earlier sign of disease than the 
direct reflex. The light reflex is impaired while accommodation 
is retained (Argyll-Robertson pupil) in degenerative diseases of 
the nervous system, especially those due to syphilis. 

The reaction to accommodation is really a convergence reaction. 
It is readily tested by holding the finger up close to the patient's 
nose, telling him to look at a distant object, and after a few seconds 
ordering him to look at the finger. The pupils should contract 
with the convergence. 

The cilio-spinal reflex is the normal dilatation of the pupil 
produced by pinching or otherwise irritating the skin of the neck. 
The reflex is lost in lesions of the cervical sympathetic of the same 


side. The light must be dim when this test is made, otherwise 
the light reflex is stronger and dominates the cilio-spinal. 


In examining the nerves of the eye it is more convenient 
to depart from the numerical order of the nerves and test first 
the external muscles and finally the fields of vision. 

All the muscles of the eye except the external rectus (sixth), 
and the superior oblique (fourth) are innervated by the third 
nerve, which also supplies the sphincter pupillae and the muscle 
of accommodation. The third, fourth and sixth nerves function 
largely as a unit. Paralysis of the third nerve is not infrequently 
partial, the levator palpebrae superioris being alone involved 
producing ptosis. To test for ptosis the action of the occipito- 
frontalis is eliminated by pushing down on this muscle so that the 
eyebrows are kept level. The degree of ptosis is then indicated 
by the power to raise the lids when the patient is told to look 
up. The peculiar expression called tabetic facies is produced 
by bilateral ptosis and the compensating contraction of the fron- 
talis muscle. 

In complete involvement of the third nerve beside ptosis 
the eye can be moved only outward and to a slight extent down- 
ward and inward; the pupil is dilated and accommodation is lost. 

Defective innervation of the extrinsic muscles of the eye 
produces either (i) strabismus; (2) limitation of movement 
of the eye; (3) diplopia. The last, diplopia, is the most reliable 
sign, since the palsy may be so slight that there is no evident 
squint or limitation in motion. That the eyes may look straight 
is no reason why double vision may not be present. 

Strabismus may be due either to the paralysis of a muscle 
or the over-action of its opponent (concomitant strabismus). 
Concomitant strabismus is present when the patient is looking 
directly forward (the position of rest for the ocular muscles); 


and the affected eye follows the sound eye in all its movements. 
The defect of parallelism of the visual axes remains the same 
in whatever position the eyes turn. In paralytic squint the eyes 
may appear normal when the patient looks forward, but a defect 
in parallelism of the axes becomes evident when the patient turns 
the eyes in a direction requiring the use of the palsied muscle. 
To test the movements of the eyeball the patient is directed to 
follow the movements of the examiner's finger upward and down- 
ward, to the right and left. 

The power of convergence is tested by holding up the finger 
about eighteen inches from the patient's nose and directing him 
to keep his eyes fixed on the finger which is then gradually brought 
nearer to his nose. Notice the degree of convergence and whether 
it is well maintained. 


The defective mobility of the eyes may be too slight to be 
detected by observing the movements of the eye; diplopia may 
then be used to indicate the muscle involved. During the tests 
for diplopia the patient's head should be supported sufficiently 
to avoid movement. The examiner holds his ringer straight up 
in front of the patient and asks him how many ringers he sees. 
Then with the ringer moved to the right side of the visual fields, 
repeat the question, then to the left, high up and low down. 
If the patient sees but one finger in each of the positions then 
there is no diplopia. If, however, in any position two fingers 
are seen, one clearly and one blurred, then diplopia is present and 
it is in order to determine which eye is affected and which muscle 
in the affected eye. Place a red glass over the patient's left 
eye and hold in front of him a lighted candle. Move the candle 
in the various positions until he sees two candles, one red, and one 
yellow. Now one image is true, one false. Determine next 


by moving the candle to the right and left which direction causes 
the images to appear the greatest distance apart. Suppose 
the patient says the red image is to the right of the yellow, and 
that the distance between the images increases on movement 
to the right; it becomes greater then on moving the candle in the 
direction of the red image. The false image is the one in whose 
direction the diplopia increases. The red image then is the false 
image and this indicates the left eye. The paralyzed muscle is the 
one which would have turned the eye in the direction of the false 
image. In the example above the red image was to the right 
of the yellow and the left eye is affected and the internal rectus 
would turn the left eye to the right, hence that is the paralyzed 
muscle. In another case one image may be higher than the other; 
vertical diplopia. Suppose the red glass to be over the left eye 
and that the yellow image appears higher than the red and that 
the distance between the images widens when the patient is told to 
look up. Applying the rule, the yellow image must be false and 
the right eye is affected. The paralyzed muscle is the one which 
would turn the eye in the direction and position of the false image 
and in our example the affected muscle must be either the superior 
rectus or the inferior oblique. Ask the patient whether the false 
image is to the right or left of the true, and whether the upper 
end of the false image slants toward the true image or away from 
it. As an example suppose the yellow candle (false image) 
is to the left of the true and the upper end slants away from the 
true image. This would indicate the right superior rectus 
muscle involved. Werner's diagrams facilitate the recollection 
of the action of the various muscles. The continuous lines on 
the diagram represent true images; the dotted lines false images. 
From the position of the false image to the right or left of the 
true image, above or below it and the slant, one may read at once 
the muscle implicated. Thus if the false image be to the right 



of the true, and at a lower level, with the upper end inclining 
toward the true image, then the left inferior rectus is involved. 
Or if the false image be higher and to the left of the true with 
an inclination away from the true image the left inferior oblique 
muscle is at fault. 

Sap. Rect. 

Sup. Rect. 

Inf. Beet. 

Inf. Beet. 

Left » 
Inf. Obi. \ 

Sup. Obi. 

/ Right 
/ Inf. Obi. 

Sup. Obi. 

Fig. 41. — Werner's diagram. 

Fig. 42. — Werner's diagram. 


When there is weakness or paralysis of the movement of both 
eyes in one direction the condition is called a conjugate palsy. 
Thus the patient may not be able to look to his right, or upwards 
or downwards. 

Weakness or palsy of lateral movement usually indicates a 
lesion of the sixth nucleus on the palsied side. Conjugate vertical 
palsies point to disease in the corpora quadrigemina or in the region 
of the oculo-motor nuclei. When both eyes are held turned in one 
direction the condition is referred to as conjugate deviation. The 


cause may be either a muscle palsy or spasm. Conjugate devia- 
tion is a common sign in meningitis, in unilateral convulsions, and 
in the early stages of apoplexy. 

Abnormal movements of the eyes may occur in certain diseases 
of the nervous system. Rhythmical contractions of the muscles 
of the eyeball, usually symmetrical and equal in both eyes are 
termed nystagmus. These movements are -more pronounced on 
voluntary movements of the eyes. In examining for nystagmus, 
direct the patient first to look straight in front and note whether 
the eyes are steady, then direct him to look to the extreme right, 
then to the left, then up and down. If there are nystagmoid 
movements, note their rate, rhythm and amplitude. Nystagmus 
may be congenital. It is a sign in cerebellar disease, multiple 
sclerosis, tuberculous meningitis and some disorders of the internal 


The nucleus of the third, fourth and sixth nerves in the floor of 
the aqueduct of Sylvius may become affected resulting in ocular 
palsy. The most common form involves the external muscles of 
the eyes; ophthalmoplegia externa. In one type the power of 
upward rotation of the eyes is lost while lateral movements are 
unaffected. The ciliary ganglia, or the short ciliary nerves 
may be alone involved resulting in dilated pupils unaffected by 
either light or accommodation: ophthalmoplegia interna. This 
type of ophthalmoplegia is not an uncommon form of post- 
diphtheritic neuritis. 

Nuclear ophthalmoplegia may be one manifestation of 
encephalitis lethargica, or of botulism. It is also occasionally a 
sequel of typhoid fever and influenza. Ophthalmoplegia of slow 
onset and progressive course suggests cerebrospinal syphilis or 
multiple sclerosis. 



As a preliminary step to examination of the fundus of the eyes 
it is necessary to learn whether the interposed media, cornea, lens, 
and humors, are clear and free of opacities. This is determined by 
examination by transmitted light using the ophthalmoscope. 
By simply illuminating the eye with a plane mirror and looking 
through the opening of the ophthalmoscope, opacities appear as 
dark shadows in the red pupillary reflex. The patient is directed 
to look up and down, right and left, so that the various parts 
of the media are observed. The location of opacities also is thus 
determined, since those in the cornea and lens move with the 
pupil, while those in the vitreous move after the eye is at rest. 

If a lens of the ophthalmoscope of +10 to + 18 diopters be 
also used there is no better way of detecting the whitish opacities 
of cataract or opacities in the cornea (interstitial keratitis). 
In this way the grayish reflex seen in some pupils will not be 
mistaken for cataract. Interstitial keratitis is a common sign of 
inherited syphilis. 

When cataract is detected it is an indication for a careful 
search for some metabolic disorder, especially diabetes. 

The examination of the fundus oculi is important not only in 
diseases of the central nervous system but in diagnosis generally. 
The changes here detected are at times more definite and signifi- 
cant for the recognition of disease than any other facts in the 
examination. The ophthalmoscopic examination ought never to 
be omitted when headache is the prominent symptom, or in cases 
of suspected nephritis. 

When the pupil is dilated by homatropin it requires very little 
experience to detect marked changes in the disc, or hemorrhages or 

Maximal dilatation of the pupil is secured by instilling into the 
eye a 2 per cent, cocaine and 1 per cent, homatropin solution. 

i, Early stage of optic neuritis; 2, optic neuritis; 3, choked disk; 4, neuroretinitis haemorrhagica in purpura; 5, albuminuric 
neuroretinitis; 6, hemorrhagic retinitis in pernicious anemia; 7, syphilitic chorioretinitis; 8, miliary tubercle of the choroid; 9, 
medullated nerve-fibers. (Sahli and Potter, "Diagnostic Methods.") 


When this combination is used in individuals over thirty years of 
age it is recommended that the examination be followed by 
instilling 3^ per cent, solution of eserin in the eyes in order to avoid 
any danger of glaucoma. 

Direct ophthalmoscopy is much easier with the modern electric 
instrument than by using reflected light, but with practice an 
examination can be made by candle light. The patient is placed 
with his back to the light which should be a little behind and just 
above the shoulder corresponding to the eye examined, so that the 
examiner can bring his own eye within two inches of that to be 
examined. The examiner faces the patient and to examine the 
right eye the observer uses his own right eye and for the left eye 
his own left. Tilt the mirror so that the red reflection of the 
fundus is seen through the pupil. The patient is directed to 
look over the examiner's shoulder at some distant object and the 
examiner tries to relax his own accommodation. This comes with 
practice as in the use of a microscope. If it can not be at once 
effected the desired result can be secured by using a — 2 D or — 3 D 
lens of the ophthalmoscope. 

After the fundus is brought into focus its several parts should 
be observed systematically. One studies the fundus to learn the 
state of the disc, and the blood vessels, and to determine whether 
there is retinitis, exudate, or haemorrhages. When the patient's 
line of vision is directly forward his disc will be seen if the examiner 
look obliquely, slightly inward. The macular region is seen by 
looking slightly outward. 

If the patient be unable to leave his bed the direct method can 
be used by the examiner kneeling at the side of the bed at right 
angles to the patient, the light being held on the pillow on the 
opposite side of the patient's head. With the electric instrument 
there is no difficulty. 


The examination of sick children is sometimes quite difficult 
on account of constant movements of the eyes. The indirect 
method of ophthalmoscopy is then of great service. The image 
observed is inverted and larger than that seen by the direct 
method, but finer details can hardly be detected. The two images 
are analogous to those secured by using the low and high power 
objectives of a microscope. In indirect ophthalmoscopy one 
uses a +10 D lens (4 in. focus) and the +2 D lens of the ophthal- 
moscope. If the examiner have a refraction error, correction 
must be made. The examiner places himself about two feet 
from the patient and tilts the ophthalmoscope until he gets the 
red reflection through the pupil. The lens (+10 D lens) is then 
interposed at about 3 inches from the eye under examination and 
moved slightly to and fro until the retina is in focus. The lens 
should be held between the thumb and first finger, resting the 
little ringer on the patient's eyebrow to steady the hand. When 
the lens is at the proper distance from the eye the pupil disappears; 
the image of the retina occupying the whole area of the lens. By a 
little practice one learns how to avoid the confusion caused by re- 
flected light from the surface of the lens by slightly tilting the lens. 

The image seen is inverted ; hence to see the nasal side of the 
disc the examiner moves his head toward the patient's mid-line 
i.e. to see the nasal side of the right disc, move to your own right. 

When a patient is delirious, or comatose, and the eyes in 
constant motion the indirect method enables one to secure a 
" fleeting glimpse" not always possible with the direct method. 
The image seen, however, lacks detail. 

What is especially looked for in the fundus of the eyes depends 
upon the character of the disease in the patient but it is far better 
to form a routine habit of examination. It saves time and pre- 
vents omissions. A practical sequence is (1) the optic disc, (2) 
the macular region, (3) the periphery, (4) the vessels. 

i, Simple atrophy of the optic disk in tabes dorsalis; 2, simple atrophy in embolism of the central artery; 3, pressure atrophy 
in glaucoma simplex; 4, neuritic atrophy; 5, papillitic atrophy after choked disk in gumma of the brain; 6, papillitic atrophy after 
thrombosis of the central retinal vein; 7, retinal atrophy from chorioretinitis following prolonged lactation with a probable syph- 
ilitic basis; 8, atrophy of temporal portion following retrobulbar neuritis from alcoholism. (Sahli and Potter, "Diagnostic 


In examining the disc notice is taken especially that the edges 
are clear and that there is normal " cupping." The color though 
variable is only so within narrow limits. 

Appearance of disc : normal, 



Macular region: haemorrhage between disc and macula, 


appearance of macula. 
Periphery: exudate, 


pigment changes, etc. 
Vessels: compression of veins, 

tortuous arteries, 

light streak on arteries, 



Gross departures from normal in the visual field, for example, 
hemianopsia , can be detected without special instruments. The 
examiner compares his own field with the patient's. Seated 
facing the patient and about three feet from him, the examiner 
holds a pencil just at the periphery of his own fields, the patient 
covers one eye and looks with the other at the eye of the examiner, 
the pencil is moved from right and left, up and down into direct 
vision. If the patient can not see the object which is visible to 
the examiner his visual field is contracted. It is necessary that 
some care be taken that the object is equidistant from both patient 
and examiner. 

For refinement of this test and detection of slight changes in 
the fields a perimeter is required. The technique varies with 
different instruments, but is in any case simple. 

Distortion of visual fields is significant in the diagnosis of a 
number of lesions of the brain and of hysteria. 








•i— i 

















The evidence derived by tests of the olfactory nerve is often 
of doubtful value since the sense of smell is so frequently impaired 
by disorders of the nasal mucous membranes. If these disturbing 
factors can be excluded disorders of this sense (anosmia) are useful 
in determining tumor of the frontal lobe, tabes, and hysteria 
(unilateral). To test for anosmia the most useful materials are 
peppermint, asafoetida and camphor. Each nostril should be 
tested separately. 


The motor division of this nerve supplies the muscles of masti- 
cation: temporals, masseters, and pterygoids. To test the integ- 
rity of this branch direct the patient to clench his teeth and then 
palpate the temporal and masseter muscles. Next direct him to 
open his mouth as wide as he can. If there be weakness of the 
pterygoid muscles of one side the jaw will deviate toward the palsied 
side. The line between the incisor teeth will serve as a guide as 
to whether there be any deflection or not. The sensory branches 
of the trigeminal nerve are tested for touch, pain and temperature. 
The sense of touch may be estimated by stroking the skin with a 
fine brush or a cotton swab. When the sense of touch is dis- 
ordered the examination should include investigation of the sense 
of pain using a pin or needle and the temperature sense using test 
tubes of hot and cold water. 

When the fifth nerve is completely paralyzed there results 

anaesthesia of the corresponding side of the face and scalp. 

This anaesthesia extends to the mid-line and includes the mucous 

membrane of the mouth and half of the tongue. Wasting of the 

masseter and temporal muscles causes the zygoma to become 

abnormally prominent, and since the sensory fibers to the muscles 


of the face come from the trigeminal nerve there results an 
awkwardness of facial movements — pseudo facial palsy. 

The sense of taste should be tested when there is evidence of 
disorder of the trigeminal nerve or when there is facial paralysis 
(chorda tympani). The materials employed for this test are 
commonly sugar, salt, citric acid and quinine. These substances 
are best used in powder form. The tongue must be kept protruded 
during the test to prevent the saliva carrying the test material to 
the other side of the tongue than that being examined. A few 
particles of each test substance are in turn rubbed on one side 
of the tongue by means of a cotton swab, and the patient is directed 
to indicate the taste of the substance by pointing to its name on a 
card on which has been written "sweet," "sour," "bitter," "salt." 
The quinine test is given last since this taste is apt to obscure the 
less pronounced flavors. 

It is necessary in estimating the sense of taste to remember that 
this sense is apt to be blunted in heavy smokers 


Asymmetry of the two sides of the face may be due to several 
causes, paralysis or paresis of the seventh nerve of the correspond- 
ing side; contracture of the opposite side; developmental defect or 
facial hemiatrophy. In order to differentiate between these 
certain tests may be of service. 

The intact innervation of the muscles of the upper portion of 
the face is shown by the ability of the patient (i) to raise his eye- 
brows, (2) to frown, and (3) to shut his eyes. The strength of the 
orbicularis oculi is tested by attempting to open the eyes against 
the patient's effort to keep them closed. 

Since the upper facial muscles are represented in both sides of 
the cortex they are not involved to the same degree as those of the 
lower part of the face in the ordinary type of hemiplegia 
(capsular) . 


The muscles of the lower face are tested by directing the patient 
(i) to puff out his cheeks, (2) to whistle, (3) to show his teeth, (4) 
to smile. 

If the facial nerve be injured below its exit from the stylo- 
mastoid foramen Bell's palsy results, a paralysis of the correspond- 
ing side of the face. There is asymmetry at rest and this 
asymmetry is exaggerated on voluntary or emotional movement. 
The patient can not wrinkle the brow nor frown on the affected 
side and the eyelids of the affected side do not close voluntarily 
and the corneal reflex is abolished, predisposing to injury of the 
cornea and to conjunctivitis. The mouth is drawn toward the 
sound side. When the patient attempts to smile or show the 
teeth only the sound side moves. Often articulation of the labial 
consonants is blurred. 

When the motor root of the facial nerve is injured within the 
pons there is usually also paralysis of the sixth nerve because of 
the proximity of the two roots before emergence. 

An impariment of emotional expression in one side of the face 
is occasionally observed when all voluntary movements are intact. 
This defect of emotional movement points to a thalamic lesion of 
the opposite side. 

In cases of Bell's palsy where recovery is delayed or imperfect a 
spastic condition of the affected muscles may occur. The mouth 
is drawn toward the affected side, the palpebral fissure is narrower 
than normal and the furrows of the face reappear and become 
exaggerated. When at rest the healthy side may seem to be the 
one paralyzed, but this appearance is corrected when the patient 
attempts voluntary movement. 

A condition which occurs in the region supplied by the fifth 
nerve, progressive facial hemiatrophy, has some resemblance to 
paralysis of the seventh nerve. This disease usually commences 
in early life and is progressive. Commencing often about the 


orbit the skin first becomes thin and atrophic and later the sub- 
cutaneous fat disappears, producing a wrinkled appearance in 
contrast to the healthy side. The disease extends involving the 
whole side of the face and implicating the muscles and bony 
structures in the atrophic process. But there is no paralysis of 
the muscles, no anaesthesia. In some cases the tongue and soft 
palate become involved. The region involved in this disease 
corresponds with the distribution of the fifth nerve which probably 
indicates some type of neuritis. 

Bilateral facial palsy is rare. The most common intra-cranial 
cause of bilateral paralysis is syphilitic meningitis. Double 
otitis media and diphtheria are the usual causes for extra-cranial 

Involvement of the facial nerve (or of the fifth and sixth) 
may be of great assistance in localizing intra-cranial lesions. 
A characteristic sign of a lesion of one side of the pons is "crossed" 
or "alternate" paralysis of the fifth, sixth, or seventh cranial 
nerve or nucleus. There is then hemiplegia of the arm and leg on 
the side opposite (contralateral) the cerebral lesion and paralysis 
of the facial nerve (or V, or VI) on the same (ipsolateral) side as 
the lesion. This "crossed" paralysis results from injury of the 
pyramidal tract before decussation and injury of the nucleus of a 
cranial nerve as illustrated in the diagram (page 191). In the 
commonest type of hemiplegia the lesion is in the internal capsule 
and there results paralysis of face and arm and leg on the contra- 
lateral side. 


Anatomically and functionally the eighth nerve consists of 
two divisions: the cochlear division subserves the function of 
hearing while the vestibular division supplies the vestibule and 
semicircular canals comprising the organ of equilibrium. 


As a preliminary to testing a patient's hearing it is necessary 
to know that the external auditory canal is free from obstruction 
(wax) and a brief otoscopic examination will often save mis- 
directed effort. If the ear appears normal the power of hearing 
may be tested by means of a watch or a tuning fork. The physi- 
cian should know at what distance his watch is normally heard. 
Standing behind the patient the watch is held outside the probable 
range and then gradually brought nearer till the patient indicates 
that he hears the tick. Each ear is tested separately, one being 
closed while the other is examined. From the neurologist's point 
of view any difference in acuity of hearing between the two ears 
is more important than the absolute acuity. 

If a difference is found it is next in order to determine whether 
the impairment is caused by a nerve lesion or disorder of the middle 
ear. Difference in air and bone conduction bear upon this point, 
and are tested with a tuning fork. 

First the handle of the vibrating fork is held on the centre of 
the forehead or on the vertex. Normally the sound is heard 
equally in both ears, and if the patient close one ear with the ringer 
the sound becomes louder on that side (Weber's Test) . Next press 
the handle of the vibrating tuning fork firmly on the mastoid 
process slanting the branches of the fork away from the external 
ear. The patient is instructed beforehand to indicate when the 
sound disappears (Rhine's Test). When he no longer hears the 
sound through the bone the fork is held close to the external 
meatus. Normally it is still audible which is to say that air 
conduction is normally better than bone conduction. This normal 
relation is maintained when deafness is due to lesions in the 
nervous apparatus or of the labyrinth but in middle ear disease 
or obstruction in the external meatus there is loss or impairment 
of air conducted sound but bone conduction is preserved 
(Negative Rinne). Likewise in middle ear disease the vibrations 


of a tuning fork placed on the vertex is heard best in the affected 
ear. (" Positive Weber.") 

When the impairment in hearing is due to disease of the 
internal ear or of the auditory nerve — " nerve deafness/' Weber's 
test is not heard on the affected side (negative Weber) and often 
air conduction is stronger than bone conduction (" positive 
Rinne"). With destructive lesions of the nerve or its nucleus 
both bone and air conduction are abolished. 

The principle abnormal auditory sensations are tinnitus, 
hyperacusis, and hallucinations of sound. 

Tinnitus takes various forms evidently and is described as a 
buzzing, humming, or ringing in the ears. These sounds may be 
continuous or pulsating. The latter occur sometimes with intra- 
cranial aneurysms, more often in debilitated or neurasthenic 
subjects. In continuous tinnitus the sound may be of high or 
low pitch. The sounds of low pitch are usually caused by circula- 
tory disorders, congestion, hyperaemia, anaemia. If venous 
hyperaemia be the cause tinnitus is aggravated by lying down 
while that of anaemia is relieved. Amyl nitrate relieves tinnitus 
due to anaemia, and may on this account be used as a test to 
differentiate from tinnitus of hyperaemia. High pitched tinnitus 
suggests labyrinthine disorder or reflex stimulation — e.g., wax in 
the external meatus, or water — but some drugs, notably quinine 
and the salicylates, may induce it. 

The vestibular apparatus is in close functional union with the 
cerebellum and is concerned with equilibration and also with 
coordination in general. 

The vestibular tests are time consuming and a severe tax on the 
patient. For these reasons they should not be carried out as part 
of a general neurological examination but should be made a 
special examination at another time. 


Violent vertigo and nystagmus are produced in the normal sub- 
ject if the drum of the ear be stimulated with either hot or cold 
water. As a consequence of the vertigo there develops a sort of 
ataxia. The test is best carried out with the patient lying on his 
back. The patient is directed to touch the examiner's finger held 
out in front of him. He then closes his eyes and is directed to 
drop his arm vertically and bring it up again so as to touch the 
target. The movement is repeated then in the horizontal plane. 
A normal person can execute these movements with considerable 
exactness with the eyes closed. The left ear is then syringed out 
with cold water (i8°— 20 C.)* which induces a horizontal 
nystagmus on looking to the right. If the pointing tests be now 
tried there is a notable deviation in touching the target — a mis- 
pointing to the left of the target. The slow phase of the nystagmus 
produced is to the left, therefore, his mispointing is toward the 
direction of this slow phase. 

The plane of deviation can be changed by altering the position 
of the head. Thus during a period of horizontal nystagmus to 
the right if the patient's head be quickly rolled toward the right 
the horizontal nystagmus is replaced by a vertical nystagmus with 
the slow phase upward and mispointing upward also. 

In this way the semicircular canals may all be separately tested. 

The special tests for vestibular functionf are particularly 
helpful in cases of vertigo, spontaneous nystagmus upward 
(brain-stem lesions) cranial nerve palsies, ataxia, and blindness. 
If stimulation of one ear be negative for nystagmus, vertigo, or 
past pointing, and if there be corroborative evidence of total 
deafness of that ear this shows destruction of the labyrinth, or 
the eighth nerve for that ear. 

* The reaction is diminished or abolished if the canal be obstructed by cerumen. 
When the drum is ruptured the test should not be employed, 
f Ann. Otology, 191 2, 12, 71. 
N. Y. Med. Jour., 1919, 109, 325. 


The term vertigo is used to designate the sensation of dis- 
turbed equilibration. This sensation may be due to various 
causes : 

1. Toxic; e.g. tobacco, alcohol. 

2. Ocular; associated with diplopia. 

3. Circulatory disorders; cerebral anaemia or hyperaemia; 
e.g. aortic regurgitation and cerebral arteriosclerosis. 

4. Vestibular vertigo : 

(a) Affections of the labyrinth; labyrinthitis, Meniere's 
disease, middle-ear affections. 

(b) Lesions of the vestibular trunk or nucleus from 
haemorrhages, tumors or gummata. 

(c) Intracerebellar affections. 

The differentiation between types of vestibular vertigo 
depends on collateral evidence. In affections of the labyrinth 
there is usually accompanying auditory disorder, difficulty 
of hearing, tinnitus; while with lesions of the nucleus or nerve 
trunk there are accompanying signs of basal or pontine disorders. 
With intracerebellar tumors of a lateral lobe there is vertigo 
and the sense of rotation of the body is in the same direction 
as the apparent movement of surrounding objects — the rotation 
is away from the side of the lesion. With extra-cerebellar tumors 
the subjective sense of rotation and the rotation of external 
objects is in the opposite direction. 

Glossopharyngeal nerve (the ninth nerve), is concerned with 
the taste sense of the posterior part of the tongue and common 
sensation of the pharynx. Tests are most conveniently made with 
a long electrode. The motor function of the IX overlaps that 
of the vagus with which it is tested. 

Vagus or Pneumogastric (the Tenth Nerve). — First the patient 
is directed to swallow and the examiner tests the force with which 
the larynx is drawn upward by deglutition. Then the patient is 



directed to say "Ah" with the mouth open and the raphe palati is 
observed. When there is a paralysis of one side the palate 
deviates to the sound side. The most characteristic sign of vagus 
affections is laryngeal palsy. Abductor paralysis, unilateral or 
bilateral, is always organic and may be the earliest sign of involve- 
ment of the recurrent laryngeal nerve. 

In paralysis of the recurrent laryngeal nerve the vocal cord 
on the affected side is immobile; fixed in the cadaveric position, 



Fig. 46. — I. Left abductor paraly- 
sis, during inspiration. II. Left ab- 
ductor paralysis, during phonation. 
III. Left recurrent laryngeal paraly- 
during inspiration. IV. Left 


recurrent laryngeal paralysis, during 

Fig. 47. — I. Adductor paresis — all the 
adductors affecte d — phonation. II. 
Adductor paresis — arytenoideus unaffected 
— phonation. III. Paralysis of the thyro- 
arytenoidei — phonation. IV. Paralysis 
of the arytenoideus — phonation. 

midway between adduction and abduction. During phonation 
the cord of the healthy side crosses the midline to meet the palsied 
cord. If both sides are paralyzed phonation is impossible. 
The common causes of paralysis of the recurrent laryngeal 
nerve are: compression from aortic aneurysms, or mediastinal 
tumors. Compression of the nerve between the dilated auricle 


and the pulmonary artery in mitral stenosis is common. Adduc- 
tor paralysis is nearly always bilateral and usually of hysterical 

The eleventh nerve is distributed to the sterno mastoid and 
the upper portion of the trapezius muscles. The integrity of 
the nerve is determined by testing the power of one sterno- 
mastoid to rotate the head toward the opposite shoulder and by 
the strength of the trapezius as shown by shrugging the shoulders 
against resistance. 

The twelfth or hypoglossal nerve is tested by examining the 
patient's ability to protrude the tongue and to move it about the 
mouth. If the twelfth nerve be paralyzed on one side the tongue, 
instead of protruding straight, is pushed toward the paralyzed side. 
The paralyzed side of the tongue also becomes atrophied and 

A combined lesion implicating the roots of the tenth, eleventh 
and twelfth nerves — Hughlings Jackson syndrome — is one of 
the common multiple palsies. The syndrome is characterized 
by paralysis of the vocal cord, soft palate, sterno-mastoid, tra- 
pezius and hemiatrophy of the tongue; all on the same side. 

Articulation is a complex coordination involving the functions 
of the fifth, seventh, ninth, tenth and twelfth nerves. Gross 
defects in articulation will be observed in the course of taking the 
patient's history, or tests may be made by having the patient 
read aloud or pronounce " catch" words: " irretrievable," " Bibli- 
cal criticism," "hippopotamus," "righteous retribution." In 
most cases difficulties in articulation will be revealed by a slurring 
of some of the consonants. 

In facial palsy the affection of the lips renders the labials 
(P,B) and the labiodentals (F,V) indistinct. 

Bilateral paralysis of the palate (e.g. postdiphtheritic palys) 
produces a nasal voice and some consonants are altered, B becomes 


M, D sounds like N. The articulation sounds like that in 
congenital cleft plate. 

Unilateral hypoglossal paralysis produces a difficulty in articu- 
lation, especially of the linguodental (S, Z, Th) and linguopalatal 
(T, B, L) consonants. 

Not only in consonantal pronunciation is disease of the 
nervous system sometimes disclosed but also in the mode of speech 
and the voice. The peculiar jerky "staccato" enunciation of 
disseminated sclerosis — " scanning speech" — is an example. 

In Friedreich's ataxia the articulation is thick and clumsy; 
the patient talks as though he had a foreign body in his mouth. 

The articulation in paresis is quite similar to that slurring 
speech of alcoholic intoxication which yet requires no description. 

The manner of speech in paralysis agitans like the gait, tends 
to hurry through long sentences or words. The voice is thin and 

A lack of precision in pronouncing certain consonants consti- 
tutes lolling speech. It is notable in children learning to talk 
when they lisp or substitute one consonant for another as bwoken 
for broken, edephant for elephant. In adults it always arouses 
the question of mental deficiency. 


Preliminary to any test of the muscles one should determine by 
passive movements of each limb that there are no mechanical 
obstructions to voluntary movements, such as might arise from 
disease of bone, ankylosis of a joint, dislocations, or scars from 
former injuries. 

In the investigation of the motor system the inquiry must 
cover five separate categories: 

1. Muscular power. Is there paralysis or weakness? 


2. Muscular tone — hypertonus (rigidity), contracture, or 
hypo tonus. 

3. Muscular nutrition. 

4. Adventitious movements — tremor, athetosis, choreiform, 
twitching, etc. 

5. Muscle coordination. 

The state of muscular nutrition is ascertained in part by the 
appearance of the limb under examination and in part by the feel 
of the muscles under the palpating fingers. The condition of the 
tone of a muscle is brought out during the tests for muscle power 
especially on passive movements. In some cases the loss of muscle 
tone is obvious; as for example, the hyperextension of the knees 
in tabes due to hypotonia. Adventitious movements are usually 
apparent during the period of examination with the possible excep- 
tion of tremor which may require a special test. It is necessary 
for the examiner to keep in mind the five points to be covered in 
the tests. 

Muscular Power. — The active movements of the head are 

tested by directing the patient to bend the head forward, backward, 

and sidewise. If the patient is not conscious passive movement of 

the head forward should be specially investigated to detect the 

resistance found in meningitis. The characteristic attitude 
of the head in paralysis agitans and cervical spondylitis is 


In testing the strength of the muscles of the limbs the patient 
is directed to perform a movement which will throw some muscle 
into action, this movement being opposed in some degree by the 

The flexors of the fingers are tested by having the patient 
squeeze the examiner's hand; the extensors by opposing resistance 
to the act of extension. Abduction and adduction are tested by 
directing the patient to separate the fingers widely and then press 


them together. These movements may also be opposed by 
the examiner. 

The strength of the opponens pollicis is shown by the ability 
of the patient to touch the tip of the little finger with the end of 
the thumb. 

Atrophy of various muscles of the hands may be significant 
of certain diseases: the thenar and interossei, for example in 
progressive muscular atrophy and syringomyelia, and lesions of the 
lower roots of the brachial plexus. Claw hand Or "main en griffe " 
is a result of paralysis of the interossei and lumbricales muscles. 

The flexors of the wrist are tested by having the patient extend 
the hand, palm up, and then flex the wrist so that the ends of the 
fingers approach the forearm. 

Direct the patient to hold the hand palm downwards with 
fingers flexed. The examiner then tells the patient to bend the 
hand backward as far as possible. Resistances may be used to 
"load" the muscle. "Wrist drop" is a weakness or palsy of the 
extensors of the wrist. 

The strength of the biceps is determined by having the patient 
hold the elbow close to the side and flex the forearm on the arm 
while the examiner offers resistance to this motion by grasping the 
wrist. The healthy biceps will stand out prominently as it 
contracts. To test the triceps, the arm is partly flexed, the 
examiner grasps the patient's wrist and endeavors to hold the arm 
in flexion while directing him to extend his arm. 

The strength of the deltoid is shown by the ability to lift the 
arm out straight at right angles to the body. 

The pectorals. Direct the patient to extend the arms in 
front of him, and next to bring the two hands together while the 
examiner tries to hold them apart. The healthy muscle will be 
seen to contract. In stout subjects it may be necessary to pal- 
pate the contracting muscle. 


The serratus magnus is thrown into contraction when the 
patient pushes against resistance — e.g., the wall. The healthy 
muscle will stand out and the scapula will remain flat to the chest. 
When the muscle is paralyzed the medial border and inferior angle 
of the scapula will project (wing) when the muscle is called upon. 

The latissimus dorsi are thrown into action when the patient 
attempts to extend the arm downward and backward. The sim- 
plest test is to have the patient cough, the examiner having his hands 
over the latissimi in the lower axillae. Contraction is easily felt. 
Or the patient may lie face downward on a bed or table and 
attempt to raise the arm backward. 

During the examination of the muscles of the arms for weak- 
ness, one notes any involuntary movements, athetosis, twitching 
or tremor. Tremor is best disclosed when the patient extends 
the hand and spreads out the ringers. 

Trunk muscles. The patient should lie flat on his back on a 
bed or table. Then direct him to sit up, keeping his arms folded. 
He will be unable to do this when the abdominal muscles are 
weak or palsied. To test the erector spinae make the patient lie 
face down and attempt to raise his head and hyper-extend the 

The integrity of the trapezius is indicated by the ability of 
the patient to shrug the shoulders and to approximate the 

The • same methods are employed for testing the muscular 
power in the legs as in the arms. With the patient lying on his 
back the flexors of the thigh are brought into use when he attempts 
to lift the leg with the knee extended. Next hold the foot off the 
bed and direct the patient to pull the leg down against resistance. 
This throws the extensors into action. Flex the patient's leg at 
the knee and then while grasping his ankle direct him to straighten 
out his leg. This movement requires the use of the extensor 



muscles of the knee. The flexors are tested by directing that he 
bend the knee while resistance is offered by the examiner to this 
movement, or the same movement may be executed with the 
patient lying face down. Adduction and abduction are examined 
by grasping the ankles of the patient and holding the legs some 
eighteen inches apart and then telling the patient to pull his feet 


M. O-fl. 

Fig. 48. — Diagram illustrating hemiplegia alternans. N.O.M. = oculomotor 
nerve. Lesion in crus at A giving rise to hemiplegia on opposite side from eye 
involvement. Lesion in pons at B crossed paralysis of face. 

together or spread them farther apart. Extension and flexion 
of the foot are analogous to these movements in the hand and the 
power of the muscles involved is determined by the examiner 
offering resistance to the movement to be executed by the patient. 
When there is a paralysis from a peripheral nerve lesion it may be 
limited to one side as in traumatic nerve palsies or it may be 
bilateral and symmetrical which speaks usually for toxic neuritis, 
that of alcohol or lead for example. 


If the examination discloses a motor paralysis the next question 
to be answered is whether the paralysis is organic or functional. 
The differentiation between a functional and organic paralysis may 
at times be easy on account of the history of the case. For 
example the development of a motor disorder following an 
emotional shock. On the other hand differentiation is at times 
difficult. Disseminated sclerosis in its early stages is notoriously 
liable to be mistaken for hysteria. There is a mistaken notion 
too, that muscular atrophy excludes functional disease. While 
infrequent in functional disease, atrophy will occur in a limb not 
used whatsoever the cause of disuse. Paralysis of an isolated 
muscle always signifies organic disease. And the electrical 
reactions of degeneration never occur in functionally paralyzed 
muscles. Both of these signs, however, refer to the lower neuron 
type of palsies. 

Babinski Test. — Babinski devised a test to differentiate 
organic from hysterical hemiplegia. The patient lies flat on his 
back on the floor or table with his arms crossed in front of his 
chest. The legs must be separated and not allowed to touch 
each other. He is then directed to sit up without using his arms. 
As he endeavors to do this the organically paralyzed leg becomes 
flexed at the hip and the heel leaves the floor. The toes of 
the paralyzed foot spread out from each other. The hyster- 
ically paralyzed limb remains touching the floor and the sign 
is absent. 

Another test is to direct the patient to raise the leg on the 
paralyzed side and hold it in the air. Again one must see that the 
legs do not touch each other, else the palsied limb may be assisted 
by the healthy one. If now the sound leg be lifted up by the 
examiner the other will fall down at once. This test depends on 
the fact that the pelvis can not be held rigid by the muscles on the 
paralyzed side and this rigidity is necessary to lift the leg. 


The character of the reflexes help also to differentiate organic 
from functional disorders. Babinski's plantar reflex is pathog- 
nomonic of organic disease (except in infancy) . The deep reflexes 
too are never abolished in functional paralyses. 


Volitional muscular movements depend upon cooperation of 
the action of several muscles. When this harmony of contraction 
is wanting the condition is called incoordination, or ataxia. When 
the muscle sense on which coordination depends is impaired this 
defect can be, in some degree, compensated for by vision. Hence 
ataxia may become more evident when the eyes are closed or 
when the subject is in the dark. Use is made of this fact in some 
tests. The patient is directed to touch the end of his nose with 
his forefinger or to bring the two forefingers together so that the 
points touch. If he be able to do this with his eyes open determine 
if he can repeat the motions with his eyes shut. 

Any inaccuracy in the movements when the eyes are closed 
must be due to a disorder in the sense of position. When there 
is incoordination of movement with the eyes open we wish to 
determine if the ataxia is increased with the eyes closed since 
this would point to loss of afferent sensory impulses. Inability 
to describe the position of a limb with the eyes closed would be 
confirmatory evidence. On the other hand if the ataxia be unin- 
fluenced by closing the eyes and the patient describes well the 
position of a limb the lesion is probably in the cerebellum or cere- 
bellar tracts. 

Incoordination is sometimes first noticed by difficulty in 
buttoning the clothes or by inability to thread a needle. A com- 
mon test is to ask the patient to pick up a pin. Incoordination in 
the lower limbs is disclosed when the patient is unable to walk 
along a straight line — e.g., the edge of a rug or crack in the floor. 



If the patient is confined to bed direct him to touch the dorsum of 
one foot with the toe of the other. 

Loss of coordination in the lower extremities is disclosed by 
Romberg's sign. The patient is directed to stand with his feet 
close together. If he can do this he then closes his eyes. If the 
patient begins to sway or start to fall the sign is positive. In 
early cases of tabes one can sometimes notice, when the patient 
is standing with the eyes shut, active movements of the tendons 
on the dorsum of the feet, picturing the balancing efforts of the 

Incoordination and ataxia may result from interference with 
afferent impulses either by lesions in the peripheral nerves, the 
spinal cord, the cerebrum or the cerebellum. Hence, ataxia is a 
sign which may occur in tabes, disseminated sclerosis or any lesion 
which injures the afferent path for muscle sense. 


The examination of the lower extremities is not complete 
without notation of the patient's gait. The gait may be altered 
by disease or injury of the bones or joints or by weakness or loss 
of muscle power or by loss of coordination without muscle weak- 
ness. The commonest example of alteration of gait from loss of 
power of a group of muscles is that resulting from hemiplegia. 
The peculiarity of the hemiplegic gait is due to the fact that the 
affected leg is not properly flexed at the knee and ankle. This 
causes the toe to drag a bit and to avoid this the patient swings 
the leg forward in a circle about the other leg rather than pushing 
it directly forward. The stride accordingly is shortened on the 
affected side. The "steppage gait" of foot drop is hardly to be 
confused with that of hemiplegia. In the steppage gait the 
patient has to compensate by an exaggerated flexion at the knee. 


The extreme of the spastic gait is exemplified in the cross- 
legged or " scissor" gait of spastic diplegia. The patient pro- 
gresses by a series of circular steps compensated for by jerky, 
swinging movements of the trunk. The ataxic gait of tabes 
dorsalis hardly requires description. The difficulty here is not 
loss of muscle power but lack of coordination. Because of this 
uncertainty the feet are kept abnormally wide apart. The 
patient lifts his feet too high, swings the leg forward like a flail 
and bangs the heel violently on the ground. He depends much 
on his eyes to correct his loss of coordination and, therefore, 
watches the ground, hence his difficulty is much increased in the 

All manner of grotesque gaits are found in hysteria. Usually 
the resemblance to the gaits of organic disease is only superficial, 
but there may be difficulty in diagnosis. The most pronounced of 
the hysterical disorders of locomotion is astasia-abasia when the 
patient can neither stand nor walk. In paralytic astasia-abasia 
if the patient be placed on his feet he falls limply like one in an 
extreme degree of alcohol intoxication. In the ataxic type, the 
patient performs all sorts of balancing efforts and seems constantly 
about to fall but does walk. The absence of muscular atrophy, 
the presence of normal deep reflexes, and normal reactions to 
electrical stimulation exclude lower motor lesions, while the absence 
of clonus and Babinski's sign exclude pyramidal tract lesions. 

A useful means of differentiation between organic and hysteri- 
cal hemiplegia is the side-gait. The test is of use when the par- 
alysis is not too severe to permit walking. To make this test the 
patient is placed on a line and directed to move along this line 
side wise to right or left. The patient with organic hemiplegia 
has little difficulty in moving toward the paralyzed side but con- 
siderable difficulty in moving toward the healthy side; the para- 
lyzed leg drags during adduction. In hysterical hemiplegia the 


side-gait is impaired in both directions irrespective of the side of 
the paralysis. 


The condition of the reflexes is so important in diagnosis that 
some of the tests are always incorporated as part of a general 
medical examination. In one sense the condition of a reflex 
is analogous to a laboratory test — it is objective, little dependent 
upon the assistance or intelligence of the patient and not subject 
to the opinion of the examiner. 

The tendon and periosteal reflexes are usually tested first. 
In order to elicit these it is requisite that the limbs of the patient 
be relaxed and free of voluntary control. A reflex hammer may 
be used, although the fingers serve very well in most instances. 

The jaw-jerk is a reflex whose center is in the pons. For the 
test the patient opens his mouth, the examiner places his finger on 
the chin beneath the lower lip and taps it sharply with his finger as 
in percussion; the result is a contraction of the masse ter muscles. 

The radial periosteal reflex is tested by having the arm extended, 
the hand semi-pronated on the patient's knee or on the table. 
A tap on the distal end of the radius produces a contraction 
of the supinator longus, with resulting flexion at the elbow joint. 
The reflex center for this contraction is the 5th and 6th cervical 

The biceps reflex is tested by grasping the patient's arm, 
the thumb resting on the biceps tendon, and tapping the thumb 
as in percussion. Contraction of the biceps results. The 
center for this reflex is the 5th and 6th cervical segments. 

The triceps reflex. The patient's arm is grasped loosely 
round the forearm, the elbow being slightly flexed. A tap on 
the triceps tendon above the olecranon produces contraction 
with extension of the arm. This reflex has its center in the 8th 
cervical segment. 


The periosteal-costal reflex is elicited by tapping on the costal 
margin in the nipple line. This induces a contraction of the 
abdominal muscles which is notable in a slight excursion of the 
umbilicus toward the irritated side. This reflex has its center 
in the 8th and 9th dorsal segments. 

To elicit the knee-jerk the leg should be flexed at the knee 
and then the quadriceps tendon below the patella is struck 
lightly with a hammer. The reflex center for the knee-jerk 
is the 3d and 4th lumbar segments. Absence of knee-jerk is 
known as Westphal's sign. When the contraction of the quadri- 
ceps is so slight as to leave doubt on the question whether the 
knee-jerk is present or not the test is " reinforced" by having 
the patient grasp his hands and pull while the tendon is struck. 

The ankle-jerk is elicited by holding the foot at a right angle 
with the leg and tapping on the Achilles tendon, which causes 
a contraction of the gastrocnemius muscle. Another way of 
applying this test is for the patient to kneel on a chair. The 
reflex center for the ankle-jerk is in the first and second sacral 
segments. In tabes the ankle-jerk may be abolished long before 
the knee-jerk disappears. A marked exaggeration of the ankle- 
jerk accompanies an ankle clonus. This phenomenon can be 
brought about in a suitable subject by grasping the leg with one 
hand and the foot with the other, having the knee slightly flexed. 
The foot is then pushed up briskly in dorsiflexion. When there 
is a clonus a rhythmic contraction of the gastrocnemius muscle 

As one proceeds in the testing of various reflexes it is often 
useful to tap various muscles, determining thereby their mechani- 
cal irritability. This irritability of muscle to mechanical stimuli 
is considerably increased in many disorders, particularly is this 
so in tetany and the Chvostek phenomenon is a unilateral facial 
contraction which results from tapping over the facial nerve 



just below the malar bone. This test is practically always present 
in children with tetany, but is also occasionally present in other 

Superficial or Cutaneous Reflexes. 

The more important superficial reflexes are given in the 
following table, along with the method of eliciting the reflex. 
Like the deep reflexes each is referable to a segmental level in 
the cord. 

Method of test 




Touching cornea 

Contraction of orbicu- 
laris oculi 


Touching uvula 

Elevation of palate 


Downward stroke from 

Contraction of trans- 

T 6- 8 


versales and dimpling 
of epigastrium 


Stroking along costal 

Transversalis and rec- 

T 8-1 o 


tus abdominalis con- 

Lower abdominal 

Stroking parallel with 

Contraction of obliq- 

T 11-12 

inguinal fold 

uus internus 


Stroking inner part of 

Retraction of testicle 

L I- 2 


Stroking sole of foot 

Flexion of hallux and 
other toes 

L 5-S.2 

Of all superficial reflexes the plantar reflex possesses the 
greatest clinical significance. For testing it the patient must be 
in a recumbent posture. The leg is flexed slightly at hip and knee 
and rotated outward, then with any blunt object such as a pencil 
or a key the sole of the foot is stroked from the heel toward the 
toes on the inner margin. One watches the movement of the great 
toe which is normally a plantar flexion. Accompanying the 
toe flexion there is notable usually a contraction of the tensor 
fasciae femoris. Too strong a stimulus induces dorsiflexion 
of the ankle which obscures the reflex under test. The normal 


plantar flexion indicates that the reflex arc and the pyramidal 
tract are intact. If on the other hand there be a lesion of the 
pyramidal tract somewhere between the cerebral cortex and the 
reflex arc in the cord then the reaction is different, and instead 
of plantar flexion there is extension of the toe — Babinski's reaction. 
Accompanying the extensor reaction of the hallux there is detect- 
able by palpation a contraction of the hamstring muscles. 

Except in infants under two years of age the Babinski phenom- 
enon is always pathological and if constantly present indicates an 
organic lesion implicating the pyramidal tracts. It is sometimes 
found for short periods after epileptic or uraemic convulsions. 

The same phenomenon may be elicited by stroking downward 
on the inner side of the tibia from the middle of the leg; or grasping 
the tibia between thumb and finger and stroking downward 
(Oppenheim's reflex). Normally there is plantar flexion the same 
as in the plantar reflex. Gordon's reflex induces the same reac- 
tion and is secured by pressing the fingers deeply between the 
heads of the gastrocnemius muscle. 

A reflex of similar significance to the plantar reflex is elicited 
by "snapping" the finger nail of the middle finger. Normally 
there is no reaction. In pyramidal tract lesions there is flexion 
of the thumb, particularly the distal phalanx. The examiner 
" snaps" the patient's finger nail by catching it with his own thumb 


The abdominal reflex is often abolished in acute disease involv- 
ing the peritoneum, for example appendicitis. In meningitis this 
may be the first reflex to disappear, and in young adults in whom 
the reflex is normally lively its absence suggests disseminated 


The examination of the sensory system is quite difficult because 
it depends upon the concentration and attention of the patient. 


It is always important to make the examination brief in order to 
avoid fatigue, since the responses are unreliable when the 
patient is tired. On that account the initial examination 
had best be one of quick orientation, leaving the details for 
subsequent test. 

During the whole of the sensory examination the patient's eyes 
should be carefully covered. Because it is important to avoid 
suggesting the answer, it is customary to direct the patient to 
answer yes when he has been touched rather than for the examiner 
to ask him, does he feel this or this? It is also important to direct 
the patient to answer as soon as he feels a sensation, otherwise 
delayed sensation may be overlooked. 

For recording areas of abnormal sensation it is convenient to 
use a skin pencil and after the examination is completed to trans- 
fer the findings to one of the usual charts. 

According to the customary order, superficial sensation is 
examined first. For this test one may use a fine, soft paint brush 
or a cotton swab, or a small piece of paper. The last is on the 
whole best since it is always obtainable and also because the 
degree of stimulus is easily controlled. 

Superficial algesia is elicited by pricking with a pin. When 
investigating the sense of pain one ought to prick hard enough to 
induce an unpleasant sensation (easily tested on the examiner's 
hand). The pin-prick is the easiest and quickest way for rough 
orientation of superficial sensation; especially is this so when the 
patient is a little tired and his attention is not readily concentrated. 
By stroking the skin with a pin superficial hyperaesthesia is 
readily detected. The instant the hyperaesthetic area is en- 
croached upon the patient winces. Hyperaesthetic areas are of 
considerable value in diagnosis; they occur as stigmata in hysteiia 
and as "the viscero-cutaneous reflex" in lesions of internal organs 
— "Head's zones." 


We test the sense of temperature by using test tubes filled with 
hot and cold water. The hot tubes should be about 50 C. 

Deep Sensation. — By this term is meant the sense of position 
which is derived by changes in the posture of the limb. In order 
to test this sense the examiner moves each limb at its several 
joints and asks the patient to state in what position the limb has 
been placed. It is, of course, necessary that the patient have his 
eyes closed or covered during the examination. Each joint is to 
be examined separately. The most common deviation from 
normal is found in the big toe joint (acroaesthesia) , which is 
common in tabes. A good plan in examining hands and fingers is 
to have the patient imitate with one hand the positions in which 
the fingers of the other hand are placed by the examiner. Another 
plan of examination of the joint sense of the upper limbs is to have 
the patient hold his arms extended in front of him, palms down, 
and then close his eyes, directing him to keep his hands quite 
still. When the joint sense is impaired the limb will slowly move 
away from the original position. (This phenomenon has been 
called tabetic athetosis.) The deep pressure sense is readily 
examined by pinching the muscles of the arm, forearm, calf and 
thigh. In some cases deep pressure sense may be lost also in the 
eye-balls, larynx and testes. This sense is most commonly 
impaired in tabes and exaggerated in neuritis. 

Combined Sensation. — The most useful example of this is the 
astereognostic sense which is tested by having the patient close his 
eyes and then placing in his hands familiar objects for him to 
recognize, such objects, for example as a knife or pencil or a key. 
Astereognosis is a symptom of brain tumor or abscess in certain 


Convulsive seizures may be a symptom of organic disease of the 
central nervous system or of a general intoxication. In children 


especially, any acute infection may be ushered in by convulsions. 
This is especially true in scarlet fever, sometimes in measles and 
pneumonia, occasionally in typhoid fever. When there is a 
spasmophilic tendency in neurotic children a mere episode such as 
the eruption of a tooth seems at times sufficient to provoke a 
convulsive seizure. Spasmophilia is a common accompaniment 
of rickets and is manifested as tetany, or laryngismus stridulus. 

The following resume indicates some of the conditions with 
which convulsive phenomena are often associated : 

Infections. — Scarlet fever, whooping cough, fermentative 
diarrhoeas (in children), tuberculous meningitis, small-pox (in 
children), tetanus, rabies, syphilis of the central nervous system. 

Toxins. — Eclampsia, uraemia, alcohol, lead poisoning. 

Organic Brain Disease. — Tumor, abscess, general paresis, 
Jacksonian epilepsy, encephalitis. 

Circulatory Disorders. — Cerebral arteriosclerosis, cerebral 
haemorrhage, Stokes-Adams disease. 

Unknown Origin. — Epilepsy, hysteria. 

The investigation indicated in any particular case would be 
determined by the age of the patient, and the history secured 
from the family. In children one would suspect first some acute 
infection, since apparently convulsions in children occur under 
conditions where adults would have rigors and chills. Fever 
then should follow the convulsive seizure. The general examina- 
tion should include the tests for meningeal involvement, the state 
of the pupils and external eye muscles, the ears, mouth and throat, 
the skin (eruptions) , and finally the reflexes, especially abdominal 
and plantar. 

In adults there is apt to be a procurable history which will give 
some clue to the possible nature of the disorder — the history of 
other seizures as in epilepsy and hysteria, or the special features 
of a chronic illness as in nephritis. The disturbance of the 


reflexes during the coma following epileptic seizures may lead to 
error. The knee-jerks may be abolished for a short period and 
later become exaggerated, and there may be an extensor plantar 

It is often stated that the convulsions of lead poisoning may 
be associated with optic neuritis. In this case there might be 
great difficulty in differentiation from uraemia since lead poisoning 
is commonly accompanied by nephritis and hypertension. 

One of Osier's aphorisms was to the effect that epilepsy first 
appearing after thirty suggests cerebral lues. Epileptiform con- 
vulsions may be the earliest symptom of dementia paralytica. 
The tremor of the face and tongue after consciousness is regained, 
along with the pupil signs are especially to be noted. The condi- 
tion of the cerebro-spinal fluid, secured by lumbar puncture, will 
differentiate from idiopathic epilepsy. 

Increased intracranial pressure from any cause may induce 
convulsive seizures. For this reason brain tumors or abscesses 
may cause epileptiform seizures. The eyes should be examined 
for optic neuritis. Occasionally chronic alcoholism produces 
convulsions, possibly because of pressure from cerebral oedema. 

Coma. — A problem in diagnosis which arises daily in the ad- 
mission ward of large hospitals is the differentiation of post- 
epileptic coma from that due to cerebral haemorrhage or poison. 
The most useful signs in recognizing postepileptic coma are scars 
of the tongue, face or head resulting from former attacks, the 
absence of the degree of flaccidity of the limbs observed in apo- 
plexy, equality of the pupils, and the recovery of consciousness in 
a brief period (an hour or less), without paralysis. In apoplexy, 
while there may be flaccidity of the limbs — it is more pronounced 
on the paralyzed side — the arm and leg fall "dead." The leg 
on the affected side lies extended but the sound leg is more apt to 
be slightly flexed. If there is involvement of the face, the clinical 


picture presents no difficulty. The pupils are usually dilated; 

sometimes unequally, the larger beings on the side of the lesion. 

The corneal reflex is abolished on the affected side. 

The deep reflexes at the onset of ordinary apoplexy are variable 

but there is an extensor plantar reflex from the beginning on the 

paralyzed side. After several hours there is a rise in the body 


Pontile haemorrhage produces signs which are in some respects 

peculiar and have at times led to confusion with coma due to 

morphine or heat stroke. In haemorrhage into the pons there is 

usually generalized spasticity of the limbs instead of flaccidity 

and the pupils may be contracted and pin point. The temperature 

is elevated, often hyperpyrexia, in contrast to the low temperature 
of opium poisoning. Pontile haemorrhage has been mistaken 

for diabetic coma since the haemorrhage may induce glycosuria. 

Acute alcoholism does not induce so deep a coma as apoplexy. 
The state is rather one of deep stupor. But chronic alcoholism 
may result in oedema of the brain and coma which closely resembles 
uraemic coma. Differentiation depends on signs of nephritis 
in the retinae, the blood pressure and the results of chemical 
analysis of the blood. 

Uraemic coma occurring in a diabetic individual is often mis- 
taken for diabetic coma. It must not be forgotten that nephritis 
is a frequent complication of diabetes in later life and that either 
uraemia or apoplexy is not rarely the terminal event. The "air 
hunger" and soft eyeball of the coma of acidosis are characteristic. 
The diagnosis of diabetic coma is not justified by glycosuria 
and ketonuria alone and unsupported by other evidence. Frac- 
ture of the skull, for example, may induce glycosuria and simple 
fasting, ketonuria. 

Fracture of the skull as a cause for coma usually offers little 
difficulty in diagnosis. When the history does not explain the 


condition there are commonly signs of trauma on the head or 
scalp, or bleeding from the nose or ears. Delayed subdural 
haemorrhage may be readily overlooked in the earlier period of the 
disorder. The case may appear one of slight concussion with 
complete recovery after a short interval. The injury may have 
been slight. Slow haemorrhage from a lacerated vein produces 
symptoms after a day or more with gradually developing stupor 
or coma which may terminate in death. This is a type of case 
which frequently brings ambulance surgeons into undeserved 
notoriety. A man is obviously drunk and has been in a fight as 
evidenced by a "black-eye;" there are no signs of fracture of the 

Fig. 49.— Tuberculous meningitis. 

skull or other severe injury and he is, therefore, taken to a police 
station rather than the hospital. A few days later he dies ! It is 
impossible to recognize chronic subdural haemorrhage early, and 
on that account when there is possibility of its existence the 
patient should be kept under observation. 

In children, coma is a more portentous phenomenon than 
convulsions. Unless the history is known and points otherwise, 
some form of meningitis may first be suspected and the examina- 
tion directed accordingly. The posture of the child in bed, 
retraction of the head, strabismus, the condition of the pupils 
are noted in turn. Purpuric spots or other rashes on the skin 


should be looked for. Besides testing the neck muscles for rigid- 
ity by bending the head forward, one notes if this movement 
induces flexion of the lower limbs at the knees and hips (Brud- 
zinski's neck-sign). This sign is more constant than Kernig's 
sign. To elicit Kernig's sign, flex the thigh to right angles with 
the trunk and then gradually extend the leg. Normally the leg 
can be extended to about 150 . In meningitis this extension may 
be limited to little more than 90 . The deep reflexes are variable 
in meningitis depending on the extent and duration of the lesions. 
The abdominal reflexes are usually abolished. When the signs 
suggest meningitis it is important to perform lumbar puncture 
promptly in order to determine the type of infection. 

Meningismus in the course of acute febrile disease may simu- 
late all the signs of meningitis. This condition is especially fre- 
quent in pneumonia. Purulent infections in the nose at times 
cause swelling of the lymph nodes beneath the sterno-clydo- 
mastoid muscle and give rise to a stiffness of the neck similar to 
that of meningitis. In a case of small abscess on the nasal septum, 
the fever, headache and stiffness of the neck has misled to the 
diagnosis of meningitis. 

The principal causes of coma may be classified as follows: 


Meningitis (tuberculous, meningococcic, syphilitic, etc.) 

Encephalitis, epidemic encephalitis, anterior poliomyelitis (cerebral type), 

Alcohol, morphin, chloral, carbon monoxid, diabetic acidosis, uraemia. 
Organic Brain Disease: 

Abscess, tumor, paresis. 
Vascular Disease: 

Apoplexy, embolism, cerebral arteriosclerosis, thrombosis. 
Disorders due to Physical Agents: 

Concussion, fracture of the skull, haemorrhage, shock, sunstroke. 
Terminal Comas: 

Typhus, typhoid, cholera, malaria, coma carcinomatosum. 



In many cases lumbar puncture is necessary to establish the 
diagnosis and determine the mode of treatment. The operation 
is simple, causes only slight pain and is not attended by special 
danger. Any hollow needle of suitable length may be employed, 
the most convenient instrument is the trochar and canula with a 
short handle made for the purpose and commonly called " lumbar 
puncture needle." The trochar should be 8 to 9 cm. in length 
for use with adults and of 12 to 14 gage. A slender needle has no 
advantage and is more apt to break easily. Local anaesthesia 
may be used, either ethyl-chlorid spray or novocaine, but the 
anaesthetic causes about as much discomfort as the operation 
and interferes with palpation. With nervous patients it is some- 
times advisable to give a small dose of morphin half an hour before 
the puncture is to be done. When the patient is delirious or 
maniacal as in cases of meningitis, it is often necessary to use a 
little chloroform to keep the patient quiet. Otherwise sudden 
movements may result in breaking the needle or make adminis- 
tration of sera impossible. 

The skin over the lower back is sterilized either with tincture 
of iodine or picric acid solution. When applying the antiseptic a 
dab of iodine on the crest of the ilium serves as a guide to the fourth 
lumbar vertebra. The whole operation should be conducted with 
respect for aseptic precautions. 

Two modes of technique are in general use. One is to have 
the patient sit astride a chair resting his head and arms on the 
back of the chair. This method is convenient but not suitable 
for very sick patients. The other method is to have the patient 
lying on his side, with knees drawn up and back bent forward. If 
the patient can not cooperate, an assistant should hold the patient 
in this posture. A sheet rolled into a band may be passed around 
the back of the neck and under the knees and tied; this will pre- 


vent sudden extension of the spine. The operator locates with 
his finger the spine of the fourth lumbar vertebra and inserts the 
needle in the space below. The needle should point anteriorly 
and slightly inclined toward the head. The tilt of the spinous proc- 
ess is variable. The needle is pushed in firmly until it reaches 
the subarachnoid spaces or meets the body of the vertebra. The 
stylet is then withdrawn to permit the fluid to flow. A rapid flow 
of fluid is to be prevented, especially in cases where increased intra- 
cranial pressure is suspected. When puncture is done to secure 
fluid for diagnostic purposes not more than 10 c.c. should be 

After the canula is withdrawn cover the wound with a small 
sterile pad and a strip of adhesive plaster. The patient should 
always rest an hour on a bed or couch, and if headache develops 
it is advisable that he remain in bed. 




Thoracic Segments 



















7 8 















Long Deep Muscles of the Back 





Levator & 

Sph. ani, 

Rectal mus" 

cles. M. 








Rectus abdominis 


Obliq. ext. abdom. 

Pectoral maj. 

Transversus abdom. 




Obliq. int. abdom 


Quadratus lumb. 


Intercostal Muscles 





Cervical Segments 











Teres min. 



Subscapular is 

Teres major 





Triceps brach. 



Supinator long. 

Supinator brevis 

Extensor carpi radial. 

Pronator teres 

Flexor carpi radial. 

Flexor pollic. long. 

Abduct, poll. long. 

Extens. poll. brev. 

Extens. poll. long. 

Extens. digit, comm. 

Extens. indicis prop. 

Extens. carpi, uln. 

Extens. dig. V prop. 

Flex, digitor. sublimis 

Flex, digitor. profund. 

Pronator quadrat. 

Flex, carpi uln. 

Palmaris long. 


Abduct, poll. brev. 

Flex. poll. brev. 

Opponens poll. 

Flexor digit. V 

Opponens dig. V 

Adduct. poll. 

, Palmaris brev. 

Abductor dig. V 






Thl 2 


L 2 

L 3 




s 2 



Tensor fascia? 


Glutaeus medius 

Glutaeus minim. 

Quadratus f emoris 

Gemellus inferior 

Gemellus super. 

Glutaeus maxim. 

Obturator intern. 







Adduct. long. 



Adductor brevis 

Obturator ext. 

Adduct. magn. 

Adduct. minim. 

Articular is gen. 



Biceps femoris 

Tibialis ant. 

Extensor halluc. long. 



Extensor digit, long. 



Peroneus longus 

Peroneus brevis 

Tibialis postic. 

Flexor dig. long. 

Flexor halluc. long. 




Extensor halluc. brev. 

Extensor digit, brevis 

Flex. dig. brev. 

Abduct, hall. 

Flex, haliuc. brev. 


Abduct, hall. 

Abduct, dig. V 

Flexor dig. V br. 

Opponens dig. V 

Quadrat, plant. 



Electric instruments* have made the examinations of the ear 
and upper respiratory tract relatively simple procedures. The 
importance of such examinations is indicated by the fact that 
otitis media is a complication in 10 per cent of the cases of scarlet 
fever, and in a slightly higher percentage of cases of pneumonia in 
childhood. "In cases of febrile disorder of obscure causation in 
children first examine the ears" is a wise aphorism to follow. A 
very simple routine in examination will prevent many of the 
absurd mistakes which are commonly made. The order of 
examination should be inspection, palpation, speculum examina- 
tion. One first notes whether there is auricular displacement; are 
the two auricles at the same angle with the side of the head? 
Marked displacement outward and forward or outward and 
downward is usually due to mastoiditis or to furunculosis of the 
cartilaginous meatus. Oedema may cause obliteration of the 
post-auricular sulcus. Post-auricular swelling with outward 
displacement of the auricle in children points to acute 

In adults, differentiation between mastoiditis and furunculosis 
of the meatus can often be made by palpation alone. Gentle 
movement of the auricle causes no pain when the inflammation 
is confined to the middle ear, but such movement is very painful 
in case of furunculosis. The auricle should be gently moved up 

* The electric otoscope is the most satisfactory instrument for the general practi- 
tioner since it is just as easily used at the bedside as in the office. Head mirrors 
with electric light attachment are also convenient. If a simple head mirror be 
used with reflected light, the mirror should be 3 to 4 inches in diameter and have a 
focal distance of 10 to 12 inches, and the orifice should be % inch. 




and down and forward. In children the anatomic relations are 
different , and the rule does not hold good. 

Next, pressure is made over areas of oedema in order to deter- 
mine the primary focus of infection. It is necessary that the 
pressure be so directed that it does not move the auricle. Gentle 
firm pressure on the mastoid process just behind the auricular 
attachment will induce pain only when the mastoid is involved. 

Fig. 50. — Normal drum membrane. 

Fig. 51 . — Acute catarrhal otitis 

If, however, the pressure be directed forward so as to move the 
auricle pain will result if there is inflammation of the meatus. 

For the inspection of the auditory canal and the drum mem- 
brane artificial illumination is necessary. There are several 
minor points in the technique of speculum examination which are 
well borne in mind. The auditory canal in adults is directed up 
while in young children it is directed downward. Therefore, in 
inserting the speculum the pinna should be drawn up and back in 



adults, and down and out in children. One uses as large a specu- 
lum as can be introduced without discomfort to the patient. 

First the external canal is examined for obstructions (cerumen, 
pus, etc.) and signs of inflammation. The drum membrane is 
recognized by its peculiar bluish-white color, characteristic 
lustre and certain landmarks. The short process of the malleus 
appears as a glistening point in the upper and anterior part of the 
membrane. From the short process a line runs downward and 

Fig. 52. — Bulging drum membrane. Fig. 53. — Acute purulent otitis media. 

backward, the manubrium mallei, and leads to the apex of the 
cone of light or light reflex in the lower and anterior area of the 
drum membrane. These landmarks are noted first since their 
prominences or degree of obliteration is significant in various 
disorders of the middle ear. 

The more important changes in the membrane in disease are 
variations in (a) color, (b) position, (c) structure, and these changes 



are to be especially looked for. In acute inflammations the color 
of the membrane changes from pearly white to pink or purplish 
red, depending on the duration of the disease. In early stages 
the injection of the membrane appears in the upper areas and 
extends downward as the disease progresses. Both acute and 
chronic inflammations of the middle ear are associated with 
changes in position of the drum membrane. In acute tubal 
catarrh and in chronic otitis media 
alike, there is some degree of retrac- 
tion of the membrane. Retraction 
is indicated by the following : (a) the 
hammer handle appears shorter and 
with a more backward slant than 
normally, it may appear more prom- 
inent and broader; (b) unusual 
prominence of the short process; 
(c) change in form or obliteration 
of the light reflex. On the other 
hand the effusion of serum or devel- 
opment of purulent exudate in the 
middle ear is associated with some 
degree of displacement of the 
membrane outward — bulging. 
This outward displacement is first 
noticed in the upper posterior 

quadrant in the region of ShrapnelPs membrane. The degree of 
displacement of the membrane is indicated by the obliteration 
of the normal landmarks (short process, light reflex, handle of the 
malleus) and the appearance of convexity of the membrane. In 
acute purulent otitis media the whole drum membrane may be 
uniformly red and bulging. 

Fig. 54. — Retracted drum 


Changes in the structure of the drum are detected by per- 
forations, by areas of opacity and by areas of abnormal trans- 
parency indicating thinness. 

Since diseases of the ear so frequently arise from abnormal 
conditions in the nose and throat, examination of the nose and 
throat is often an essential factor. This is especially true in 
children. The presence of adenoids or of enlarged tonsils becomes 
important in any febrile infection, particularly in scarlet fever 
and pneumonia. In young children it is difficult to use a mirror 
to see adenoid growths in the roof of the naso-pharynx. It is 
better to trust to the palpating finger introduced through the 
mouth. Definite hypertrophy of the tonsils is obvious, but it 
is difficult to know where to draw the line between normal and 
moderate hypertrophy. Some authorities hold that a tonsil 
demonstrable to inspection represents an abnormal growth. 
But more important is the question of infection, and infected 
tonsils are not always enlarged. The history of recurrent attacks 
of tonsillitis is equally as important as the appearance of the 

Examination of the post-nasal space and of the larynx by 
means of a laryngeal mirror is indicated in various conditions 
(asthma, hoarseness in tuberculosis or cardiac disease, aphonia, 
etc.). The examination is not difficult, especially if the throat 
be sprayed beforehand with a 5 per cent, solution of novocaine. 
The special requisites in technique are dexterity in avoiding irrita- 
tion of the soft palate which provokes gagging or coughing, and 
training one's self to see quickly. Again the electric head 
light is of great convenience. The examiner grasps the end 
of the patient's tongue in a piece of gauze. The mirror, which 
should be quite warm, is introduced with the other hand, the 
handle of the mirror is at first kept low so that the mirror follows 
the roof of the mouth. When the posterior pharyngeal wall 


is reached the handle of the mirror is turned so that the structures 
to be examined are brought into view. The patient is then 
directed to say "A" or "Ah" which will elevate the soft palate 
out of the line of vision. 


Fig. 55. — Paget's disease, osteitis 

In the examination of the limbs 
we are looking not only for evidence 
of local disease but also for local 
signs of general disease. 

Peculiarity of the gait, or a limp, 
at once excites attention. Besides 
those due to nervous disease, more 
or less characteristic gaits result 
from congenital dislocation of the 
hip, rickets and flat-foot. A few 
diseases produce a characteristic 
posture, as that of Parkinson's dis- 
ease, and a type of lethargic enceph- 
alitis. One may be struck at once 
by the position of the limb which is 
characteristic not only in certain 
fractures but also in palsies, especi- 
ally of the lower extremities. Asym- 
metry may be the result of wast- 
ing or of disproportionate growth. 
The short extremities of achondro- 
plasia are characteristic. 

There will be noted also changes 
in color, cyanosis, pigmentation, 
or rashes; changes in shape due to 
edema or localized tumefactions. 
The nature of any abnormality noted 
by inspection will be further deter- 


mined by palpation. In cases of rashes or skin diseases 
besides the duration, distribution and subjective symp- 
toms, the character of the lesion must be determined — macula, 
erythema, papule, nodule or infiltration; vesicle, bulla, pustule or 
wheal. And there are also secondary characteristics such as 
scaling, scabs, excoriations from scratching, or ulcers. Examples 
of skin lesions characteristic of general disease are those of syphilis, 
tuberculids in children, and pellagra. 

Fig. 56. — Tetany. 

The character of an infiltration of the skin, or of an area appar- 
ently inflammatory, is indicated not only by its size, and the tissue 
involved — skin, muscle, periosteum — but also by the evidences of 
inflammation and whether the lesion is single or multiple. Abscess 
in the soft tissues is not uncommon. It is suggested by the cardi- 
nal signs— pain, redness, heat and swelling. Fluctuatior may be 
felt at the center of the abscess if gentle pressure be made with the 
fingers at some other point on the inflamed area. It is necessary 
to guard against false fluctuation which occurs when palpating 
across muscular fibres. In the early stages of an abscess a softened 
circle can be determined by gently passing the finger over the 


surface. The area of necrosis will be circumscribed by a hard 
edge. A rapidly growing sarcoma has been mistaken for an 
abscess. When there is doubt the area should be punctured with 
a needle. Softening gummata show no inflammatory reaction 
unless there be secondary infection. In this respect they resemble 
tuberculous abscesses. Gummata are rather hard, sometimes 
doughy tumors, rarely single and often painful at night. 

Cellulitis is to be differentiated from abscess by the streaks 
of redness indicating lymphangitis, the enlarged and tender 
lymph nodes in groin or axilla, and the indefinite border of the 
inflamed area. Sinuses and fistulae distal to a joint suggest 
osteo-myelitis; proximal to a joint tuberculosis. 

Varicose ulcers of the lower extremity are common. They 
are to be differentiated from ulceration due to syphilis, diabetes 
or arterio-sclerosis. This differentiation rests mainly on asso- 
ciated signs, varicose veins, evidence of syphilis elsewhere, gly- 
cosuria, et cetera. Syphilitic ulcers have sharp margins, are 
"punched out," occur more often on the external side of the leg, 
and tend to heal on one side and progress at the other. Since they 
occur often with varicose veins, differentiation must depend on 
other signs — e.g. vascular, or on the result of a Wassermann test 
or the effect of anti-luetic treatment. 

The commonest deformities (excluding trauma) are those due 
to rickets, arthritis, and infantile paralysis. Less common but 
not unusual deformities result from acromegalia, gout and syphi- 
lis. In children, tuberculous and luetic dactylitis produces a 
characteristic fusiform enlargement of one or more fingers. 
The " sabre-shin" — anterior bowing with sharp, rough edge of 
the tibia — is suggestive of syphilis. 

Hyperesthesia to touch or on motion should never be ignored 
in children. It may suggest scurvy, infantile paralysis or early 
meningitis. Congenital syphilis in children may lead to epiphysi- 



tis with separation and loss of use of the limb (pseudo paralysis) . 
The condition is apt to be associated with periostal thickenings of 
the skull (Parrot's nodes) and other signs of congenital lues. 

The most common bone swellings are due to infections, either 
periostitis or osteomyelitis. If the swelling is near a joint 
tuberculosis has to be considered. 

Swelling of a joint may be due to either an acute or chronic 
involvement. The causes for acute inflammatory arthritis are, 

Fig. 57. — Subcutaneous fibroid nodules. 

in order, rheumatic fever, septic arthritis (scarlatinal, meningitis) 
gonorrheal arthritis, and arthritis secondary to bone disease 
adjacent to a joint. The common causes of chronic arthritis are 
arthritis deformans, displacement of a semi-lunar cartilage in the 
knee, tuberculosis, Charcot joint, gout, and syphilis. The facts to 
foe determined in examining the joint are, is the swelling due to 



increase of fluid in the joint or to inflammation of the periarticular 
tissues or to an increase of tissue — (tumor, cysts) — or to new 
bone growth? These facts are all determined by palpation. 

Tremor is a notable sign in a number of disease states, especially 
Graves' disease, neuro-vascular asthenia, multiple sclerosis, and 
some chronic intoxications. Tremor is best demonstrated when 

Fig. 58. — Elephantiasis (non- filarial). {Case of Howard Fox, M. D.) 

the patient extends the arm and separates the fingers. If tremor 
be present the next question would be, is it increased or decreased 
by volitional movement— on attempt to pick up an object. And 
is the tremor a coarse or a fine one? 



The examination of the extremities is concluded by palpating 
the lymph nodes. Those of the groin and axilla are usually 
palpable in adults, but not the epitrochlear nodes. The latter 
when enlarged are easily felt in the inner aspect of the arm, just 
above the inner condyle of the humerus, near the artery. General 
glandular enlargement occurs in syphilis, glandular fever, and 
some of the primary blood diseases. 

Fig. 59. — Chronic arthritis. 


In examination for any disease of the joints whatsoever 
the data are most easily collected by having an orderly routine. 
The diseases which are of most importance relative to the joints 
of the lower extremities produce changes in gait, attitude in 


standing, deformities, etc. On inspection we note particularly 
the following: 


attitude on standing, 

relative size of the joint, 

bony prominence, 



muscle atrophy. 
By palpation we confirm impressions received from inspection 
and make further tests. These involve 

muscle tone or spasm, 

skin temperature over the joint, 

the character of the swelling (fluid, boggy, bone), 

mobility, or its limitation (both active and passive), 

tenderness to pressure, 

With those exceptions which relate to gait, attitude on stand- 
ing, etc., the examination of the joints of the upper extremities 
covers the same headings. The data secured by this type of 
examination, along with the age of the patient and the history, 
constitute in the main the facts on which diagnosis is established. 
For example, tuberculosis of the hip is usually characterized in 
its earliest stage by limp, pain (often referred to the knee and 
usually at night) , very slight deformity, usually flexion with abduc- 
tion. At a later stage there may be also atrophy of muscle groups, 
limitation of motion, with adduction and rotation. Pain on 
passive motion is elicited when the head of the femur is forced into 
the acetabulum either by direct pressure or by striking the heel 
when the leg is abducted. When a definite diagnosis can not be 
established by the aid of an X-ray a tuberculin test should be 
resorted to. Other conditions which can give rise to similar 



physical signs are non-tuberculous infections, acute epiphysitis, 
coxa vera, neoplasm, and hysteria. 

The same general principles cover the examination of the 
spine. The significant facts to be elicited are pain, limitation of 
motion, and deformity. It is useful to mark with a skin pencil the 
spinous processes in order that when the patient bends from one 
side to the other side any defect in the normal curve will be more 
readily seen. In children the pain is frequently referred to the 
abdomen. A curious symptom occasionally complained of 
by adults with early Pott's disease is sudden muscular incapacity 
when any movement is made involving the trunk muscles. 

Fig. 60. — Myositis ossificans. 


The significant facts on which the diagnosis of the type of bone 
tumor rests are the age of the patient, the part of a bone involved, 
the character of the growth and the presence or absence of bone 
production in the growth. For example, a malignant growth 




appearing in the bones of an individual over fifty years of age 
is probably metastatic carcinoma; purely on probability, if the 
patient be a woman the primary growth is in the breast, if a man 
in the prostate. 

Since a carcinomatous growth is conveyed by the blood stream 
to the bone, the metastasis is apt to appear near the entrance 

to the nutrient canal. Sarcoma, 
on the other hand, is more com- 
monly found at the ends of the 
bones and sarcoma occurs in the 
first and second life periods and 
rarely in individuals over forty. 
Hypernephroma may metastasize 
in any bone of the upper extrem- 
ities and, like carcinoma, it takes 
origin in the medulla. X-ray ex- 
amination is usually necessary in 
order to determine whether there 
is, or is not, bone production. 
Bone production is absent in 
carcinoma but also in some types 
of sarcoma, namely the round- 
cell, spindle-cell and giant-cell 
types. Bone production is found 
with osteoma and osteosarcoma. 
There is another distinction 
which, though not infallible, 
is sometimes of help. In benign bone tumors, associated 
with bone production, the striae tend to be parallel to the shaft, 
whereas in malignant tumors the striae may be perpendicular 
to the shaft. There are exceptions to this rule. 

Fig. 6i. — Myositis ossificans. 


The differential diagnosis of lesions of the breast depends more 
on palpation than any other factor. In the diagnosis of other 
types of disease it is customary to secure the history of the patient 
before making the examination. In examination of the breast 
Bloodgood suggests very wisely that it should be the invariable 
rule for the examiner to know nothing about the history of the 
patient. The history may be taken by somebody else and the 
patient should be instructed that during examination she is not 
to say anything to the examiner of what she is complaining or 
what she or anyone else may have felt in the breast. In deter- 
mining the character of early lesions of the breast at least, this 
rule is a safe one and can be recommended. 

For a proper examination the position of the patient is impor- 
tant. She should be stripped to the waist, and recline on a couch 
or on a bed, with the head in a comfortable position on a pillow 
and the arms raised above the head. In this reclining position, 
with the arms elevated, inspection is facilitated, especially of the 
axillary portion of the breast. Tumors may be seen in the axillae. 
Also in this position it is possible to note the bulging due to a 
tumor in the breast. Tumors which are visible on inspection are 
usually malignant. To be noted also under inspection are any 
changes in the nipple and the size of the breast. The nipples 
are to be carefully inspected for any scaly areas, warty growths 
or eczematous areas. The characteristics of Paget's disease 
are a bright red granular surface, induration with a well defined 
edge, profuse eczematous appearance with crusts. These condi- 
tions can be simulated by eczema due to a discharge from the 





Bloody discharge from the nipple may be due to carcinoma, 
papilloma or sarcoma (rare) . Slight serous discharge is the initial 
symptom in 50 per cent, of benign intracystic papillomas; it is the 
initial symptom in only 1 per cent, of the cases of malignant disease. 

Asymmetry in the size of the two breasts is not uncommon. 
One breast may be so much larger than the other that it consti- 

Fig. 62. — Paget's disease of the nipple. 

tutes a unilateral hypertrophy. To decide whether both breasts 
are on the same level have the patient sit up, and while she is 
in this position notice the profile of each breast. A flattening of the 
arc of the breast suggests shortened trabeculae. 

Retraction of the nipple when recent and not associated with lacta- 
tion should be considered a sign of cancer. Exceptionally retraction 
may be due to benign tumors and mastitis. Retraction of the 
nipple may be congenital but it should not be regarded as con- 
genital unless the patient gives a clear history of the condition. 



The object of palpating the breast is to determine, first, tumor; 
next, its character and nature. Palpation should be conducted 
with the flat finger surfaces and not the ends of the fingers. The 
best method is to palpate the two breasts at the same time, the 
right breast with the left hand and the left with the right, palpat- 
ing the corresponding areas. The nipple and the surrounding 
region should be left till last. Next, each breast should be 

Fig. 63. — Elevation of nipple due to carcinoma. 

palpated with both hands, demarking especially the edge of the 
breast and, finally, the breasts should be palpated between the 
fingers and the chest, while moving the fingers as when playing 
the piano. This method is especially recommended by Bloodgood. 
It is important to remember that the examination is likely to 
cause congestion of the breast and, on that account, increase 
in the consistency of the glandular tissue. This initial congestion 
subsides after a few minutes. This explains the definite lumps 



which may be felt in the outer and upper quadrant in the beginning 
of the examination but can not be verified later. This type of 
congestion is more apt to occur just before the menstrual period 
and in young and unmarried women. 

Experience shows the greatest difference in consistency of the 
breast, not only the amount of fat varies but the disposition of the 
gland tissue in some breasts is such that it imparts a lumpy feeling 

Fig. 64. — Carcinoma of the breast. Showing retraction of the nipple. 

to the palpating hand. Only experience serves to differentiate 
these variations in normal consistency. In some cases it is difficult, 
if not impossible, to differentiate between cystic mastitis and this 
peculiarity of the gland tissue which is apparently normal. Multi- 
ple tumors, especially when in both breasts, are more apt to be 
benign. If it is determined that there is a circumscribed tumor 
two questions arise for decision concerning it, its consistency and 


evidences of invasion — neoplastic. Malignant tumors are harder, 
excepting in their earlier stages, than benign tumors. In some 
cases they are exceedingly hard. Much depends on determining 
the invasiveness of a tumor and, therefore, special methods of 
examination are in use to determine this point. For example, one 
looks for dimpling of the skin over the tumor mass, or one may 
endeavor to pick up the skin from the subcutaneous tissue. Like- 
wise the tumor may be rolled underneath the skin in the endeavor 
to bring out a dimple. The attachment of the tumor mass to the 
subjacent pectoral muscle is a significant point. A recent retrac- 
tion of the nipple in the presence of a definite tumor usually means 

Invasion of the breast tissue can sometimes be best demon- 
strated by moving the breast from side to side or up and down over 
the underlying muscles (the patient being on her back) , and noting 
whether there is any dimpling of the skin, which may appear on 
such excursions of the breast though not visible when it is at rest. 

Glands along the lower border of the pectoralis minor muscle 
should be palpated for and likewise the glands of the axillae. 
Enlargement of the glands of the axilla may be due to several 
causes other than metastases. With single indefinite tumors in 
the breast differentiation is to be made between chronic mastitis, 
benign adenomata and cancer. 

The examination of the breast in acute mastitis is simple. 
It does not require the painstaking care already outlined. A 
swollen breast in a lactating woman, or following an injury, 
superficial signs of inflammation, the definite increase in consis- 
tency and tenderness all point to a diagnosis. 

Tuberculosis of the breast is an uncommon condition but not 
extremely rare. It occurs usually secondary to tuberculosis 
elsewhere in the body. Well defined tuberculous tumors may be 
mistaken for carcinoma. 



The Use of Tuberculin in Diagnosis. — The value of tuberculin 
as a diagnostic agent is no longer questioned. When properly- 
used it gives valuable information as to the presence or absence 
of tuberculosis. 

There are three satisfactory methods of using tuberculin: 

The cutaneous methods of Von Pirquet and of Moro, and the 

subcutaneous method. The ophthalmic method of Calmette and 

Wolff-Eisner has been abandoned because of an element of danger 

in it, and this test will not be described. 

In all methods " Old" tuberculin is employed in some dilution.* 
The Von Pirquet tuberculin test is the simplest to do, but its 

use is largely limited to children since so many adults who have 
no evidence of clinical tuberculosis react positively to the test. 
Failure to react in either child or adult is evidence of the absence 
of tuberculosis. The test is negative in healthy children under 
two years of age. The procedure for the test is as follows: The 
skin of the forearm is carefully cleaned with ether (alcohol, soap 
or water must not be used), using a pledget of absorbent cotton. 
A drop of Koch's Old Tuberculin (undiluted) and a drop of gly- 
cerin bouillon are placed on the skin about two inches apart. With 
a scarifier the skin under each drop is abraded, first the control 
and then the test. The technique is similar to that of vaccina- 
tion. The abraded area should have a circular form. 

If the patient is tuberculous the area where the tuberculin 
was applied will show signs oi a local reaction within forty-eight 

* The tuberculin in proper dilution for the various tests and glycerine bouillon 
for controls may be had from the Mulford Company and other manufacturers. 



hours. These signs are a papule surrounded by a hyperaemic 
zone an inch or more in diameter. A brownish pigmentation 
may appear following the subsidence of the reaction and persist 
for several weeks. The control area will show only slight hyper- 
aemia or none at all. A positive reaction is not attended by 
any general symptoms, nor by fever. 

The Moro cutaneous reaction is induced by applying an oint- 
ment containing tuberculin to the skin. The ointment is made 
up of equal parts of "Old" tuberculin and anhydrous lanolin. 
About half a gram of this ointment is rubbed into the clean skin 
of the chest or abdomen. The skin should first be scrubbed with 
soap and water, washed with alcohol and finally with sterile 
water to remove the alcohol. The application should be made 
to an area about two inches square and the ointment should be 
rubbed in vigorously for a minute. The area is covered with 
oiled paper after applying the ointment. A positive reaction 
is characterized by a local efflorescence which appears in twenty- 
four to forty-eight hours. The area may be simply granular 
or papular. The efflorescence fades after a few days leaving 
a brownish pigmentation which remains for several weeks. There 
are no general symptoms. 

A control test is advisable using lanolin alone with the same 

Tuberculin may be used intradermally for diagnosis as sug- 
gested by Mendel. The chief difficulty in the technique of intra- 
dermic tests in general is the necessity of using syringes which 
are clean not only in a bacteriological sense but chemically 
clean as well. Any chance protein contamination may induce a 
local reaction. 

A 1 to 10,000 dilution is used for the test and 0.005 mg. of 
old tuberculin is injected. The injection is made in the same 
way as in the Schick test. (See that section.) 


All the tuberculin tests are specific. A reaction is indicative 
of tuberculous infection, but it is not necessarily indicative of 
active clinical tuberculosis. Many, perhaps the majority of 
healthy adults, harbor tuberculous foci. For this reason a positive 
cutaneous reaction is not regarded as very significant in diagnosis 
of disease in adults. The Moro percutaneous test, while not so 
delicate as the other tests is much used in Europe though it 
has never met wide favor in America. The cutaneous tests 
find their best field in diagnosis of diseases of childhood, especially 
children under two years of age. A negative cutaneous reaction 
in an adult may be significant since it would to some extent 
argue that the individual was free of tuberculous infection. 

The use of tuberculin by the subcutaneous method has a 
wide field of usefulness in diagnosis. Properly used it is harmless, 
and some believe it of positive benefit to the patient. 

A careful record of the temperature and pulse of the patient 
to be investigated should be kept for several days before the test 
is made. The test can not be interpreted unless the patient is 
afebrile. For twenty-four hours preceding the test and for thirty- 
six hours after, the temperature is taken every two hours. The 
patient is kept in bed. The initial dose of dilute old tuberculin 
should not be larger than 0.5 mg., some use 0.05* mg. If no 
reaction follows this the same dose is to be repeated after three or 
four days since in some cases a reaction will then occur. If there 
is still no reaction the dose is increased. A rise in temperature of 
i° F. is considered a positive reaction. The development of 
general or local phenomena is also important, even when no 
significant elevation of the temperature occurs. The presence of 
rales in an area where there were none before or the occurrence of 
general symptoms is considered positive evidence. 

* The tuberculin may be purchased diluted so that a given dose can be 
estimated in minims. 


The maximum dose for diagnosis is 10 mg. The test is exten- 
sively used in the diagnosis of early pulmonary tuberculosis and 
of tuberculosis of the bones and joints. It may be used in the 
diagnosis of any obscure afebrile disease when tuberculosis is a 
possibility. No help is afforded by the test in cases of tuberculous 
meningitis or general miliary tuberculosis. 


The chief difficulty in the prevention of diphtheria is the large 
number of healthy carriers. It has been estimated that in cities 
1 per cent, of the population during the winter months carry 
diphtheria organisms in the throat and nose. It is impossible to 
isolate these groups of healthy individuals, even though it were 
feasible to examine the entire population to detect the healthy 
carriers. The only remedy for the situation is to detect the 
individuals who are susceptible to diphtheria. Especially is this 
desirable when young individuals have been exposed, but it is to 
be remembered too that more than one half of all diphtheria 
cases occur in persons who, so far as can be learned, have not 
been in contact with cases of diphtheria. 

It is now known that only those individuals contract diphtheria 
who have no antitoxin or only minute amounts of it in the blood. 
In 19 13 Schick devised a method of estimating whether antitoxin 
be present or not. This reaction, or Schick test, depends upon the 
local action of minute quantities of diphtheria toxin injected intra- 
cutaneously. If antitoxin be present in amounts insufficient for 
protection from diphtheria a positive reaction will appear at the 
site of injection. The Schick test separates the immunes from the 
non-immunes. The test is done by injecting intra-cutaneously a 
fresh solution of diphtheria toxin of such strength that 0.2 cc. 
represents 3^50 of the minimum lethal dose of toxin for a 250 gram 
guinea pig. The toxin used should be freshly prepared and is of 


questionable value after it has been diluted for more than 12 
hours.* The diluted toxin mixture is injected by means of a 
small bore syringe (1 cc. Record) and a fine steel or platinum- 
iridium needle. The best site for the injection is the flexor surface 
of the forearm. The injection should be made intracutaneously 
and a good guide for the insertion of the needle into the proper 
layer of the skin is to be able to see the oval opening of the needle 
through the superficial layers of the epidermis. A properly made 
injection produces a distinct wheal-like elevation. Exactly 0.02 cc. 
of the diluted toxin should be injected. The result of the test 
must be read at the end of 24, 48, 72, 96 hours. The reaction 
may be either a positive, negative or a pseudo-reaction. 

A positive reaction indicates the action of an irritant toxin 
upon tissue cells unprotected by antitoxin. It indicates therefore 
that the individual is not immune to diphtheria. A slight redness 
slowly appears at the site of the injection during the first 24 hours 
and usually there is a distinct reaction in the course of 24 to 48 
hours. The reaction reaches its height on the third or fourth day 
and gradually disappears, leaving a definitely circumscribed area of 
brownish pigmentation. This pigmentation may persist for 
several weeks. At its height the positive reaction consists of a 
circumscribed area, one to two centimeters in diameter, which is 
red and slightly infiltrated. The degrees of redness and infiltration 
are variable. A negative reaction is indicated when the site of 
injection remains normal. This reaction indicates that the indi- 
vidual is immune. A pseudo reaction is a local anaphylactic 
response of the cells to a foreign protein. Like other anaphylactic 
phenomena the reaction occurs early, within six to twelve hours, 
is of an urticarial nature, reaches its height in thirty-six to forty- 

* Diphtheria toxin and a simple means for diluting it is prepared as a standard 
unit by Mulford and several other manufacturers of biological products. Also 
the antitoxin mixtures for active immunization are available. 


Fig. 65. — Shows four typical positive Schick reactions of varying degrees of intensity forty-eight 
hours after test: (a) is a strongly positive reaction, with vesiculation of the surface layers of the epithelium, 
which is seen occasionally in individuals who have practically no antitoxin; (b) and (c) are positive reac- 
tions; (d) a moderately positive reaction. (Zingher, "American Journal of Diseases of Children," April, 

Fig. 66. — Shows a fading positive Schick reaction one to four weeks after test in various stages of 
scaling and pigmentation: (a) shows redness, scaling, and beginning pigmentation after one week; (b) and 
(c) pigmentation after two and three weeks; (d) faint pigmentation after four weeks. (Zingher, "Ameri- 
can Journal of Diseases of Children," April, 1916.) 


Fig. 67. — Shows two pseudoreactions forty-eight hours after test, and a combined reaction: (a) 
mild; (b) marked; (c) a combined positive and pseudoreaction. (Zingher, "American Journal of Diseases 
of Children," April, 1916.) 


eight hours, and disappears on the third or fourth day, leaving a 
small patch of pigmentation and little or no scaling. 

A combined reaction represents a positive and pseudo reaction 
in the same individual. The central area of redness is better 
defined and larger and there is more infiltration. The reaction 
is recognized by the evidence of a true reaction and a definite 
area of scaling pigmentation after the pseudo element has dis- 
appeared. A similar reaction may be obtained in a controlled 
test with heated toxi'n. It is safest to regard a combined reaction 
as indicative of lack of immunity. 

When the reaction is positive, or when on account of doubt the 
reaction is considered positive, active immunization with toxin- 
antitoxin should be instituted. 


Abdomen, acute surgical, 140 

examination of, 52, 124 

palpating, 124 

quadrants of, 125 
Abdominal cavity, fluid in, determina- 
tion of, 53 

disease, acute, 139 

pain, 140 

reflex, 199 

tumidity, patterns of, 52 
Abductor paralysis, 185 
Abscess, 219 

cellulitis and, differentiation, 220 
Accidental murmurs, 100 
Acholic stools, 131, 132 
Achondroplasia, 31, 218 
Achylia, 127 
Acidosis, 132 
Acoustic nerve, 180 
Acroesthesia, 201 
Acuity of hearing, 181 

of vision, 163 
Acute abdominal disease, 139 

surgical abdomen, 139, 140 
Adams-Stokes disease, 77 
Adductor paresis, 185 
Adenoids, 216 
Adherent pericardium, 107 
Adults, mastoiditis in, furunculosis of 

meatus and, differentiation, 212 
Affections of myocardium, 101 
Air hunger, 204 

in pleural cavity, 74 
Alcoholism, acute, coma of, 204 

chronic, convulsions from, 203 
Algesia, superficial, 200 
Amyl nitrate in tinnitus, 182 
Anal region, inspection of, 54 
Anamnesis, 20 
Aneurysm, 87 

intracranial, 182 
Anisocoria, 36 
Ankle- jerk, 197 

Anosmia, 177 
Aortic insufficiency, 76, 91 
characteristic signs, 97 

stenosis, diagnosis of, 98 

valvular disease, 97 
Apoplexy, 169 

postepileptic coma and, differentia- 
tion, 203 
Appetite, 119 
Area, Bamberger's, 104 
Argyll- Robertson pupil, 36, 164 
Arms, "muscular power of, testing, 190 
Arrhythmia, 77 

sinus, 78 
Arteries, retinal, examination of, in 
Arteriosclerosis, in 
Artery, cerebral, syphilitic thrombosis 

of, 176 
Arthritis, acute inflammatory, causes 
of, 221 

chronic, 223 
causes of, 221 
Articulation, difficulties in, 186 
Ascites, 137 
Assembling of data, 20 
Astasia-abasia, 195 
Astereognosis, 201 
Astereognostic sense, 201 
Asthenia, cardiovascular, 94 

neurovascular, 94 
Asymmetry of face, 178 
Ataxia, 193, 194 

Friedreich's articulation, 187 
Ataxic gait of tabes dorsalis, 195 
Athetosis, tabetic, 201 
Atrophy of muscles of hands, 189 
Auditory canal and drum membrane, 

inspection of, 213 
Auenbrugger, 17 
Auricular displacement, 212 

fibrillation, 80, 81 
Auscultation, 17 

transdigital, 44 




Auscultatory method of determining 

blood pressure, no 
Axes, visual, defect of parallelism of, 166 

Babinski's plantar reflex, 192, 193, 199 
Bacteriologic examination of stools, 134 
Bamberger's area, 104 
Bell's palsy, 179 
Biceps reflex, 196 

strength of, testing, 189 
Bilateral facial paralysis, 180 

paralysis of palate, 186 
Biot breathing, 43 

Blanching of skin in percussion, 42 
Block, heart, 77 
Blood in stools, 133 

pressure, auscultatory method of 
determining, no 
normal, 109 
Bloodgood, 227, 229 
Bloody discharge from nipple, 228 
Bones, carcinoma of, 226 

hypernephroma of, 226 

sarcoma of, 226 

swellings, 221 

tumors, 225 

benign, striae of, 226 
Botulism, 169 
Bradycardia, 77 
Brain lesions, 173 
Breast, asymmetry in size, 228 

carcinoma of, 230 

consistency of, 230 

examination of, 227 

in acute mastitis, 231 

palpating, 229 

tuberculosis of, 231 

tumors of, malignant, 231 
Breath, peculiarities of, 37 
Breathing, Biot, 43 

Cheyne-Stokes, 43 
Broadbent's sign, 107 
Bronchopneumonia, diagnosis of, 65 
Brudzinski's neck-sign, 206 
Bruit d'airain of Trusseau in pneumo- 
thorax, 75 
Bulging of drum membrane, 215 

Cancer, diagnosis of, in pelvic dis- 
orders, 155 
elevation of nipple due to, 229 
metastatic, 226 
of body of uterus, 156 
of bones, 226 
of breast, 230 
of cervix, 155 

of esophagus with stenosis, 123 
of tongue, 121 

retraction of nipple as sign of, 228 
Cardiac decompensation, 95 
dilatation, grave, 102 

resultant to mitral disease, 95 
disease, murmurs in, 90 
diastolic, 91 
due to lesions of auriculo-ven- 

tricular valves, 92 
systolic, 91 
pulse in, 77 

acceleration of rate, 77 
auricular fibrillation, 80, 81 
dropped beats, j8 
irregularity of, 77 
pulse deficit, 82 
pulse pressure, 84 
pulsus alternans, 8^ 
regular irregularity in, 79 
slowing of, 77 
size of heart in, 84 

dilatation of ventricles as 

cause of, 89 
fluid in pericardial cavity, 90 
hypertrophy of high degree, 84 
location of apex impulse in, 86 
enlargement, index of, 88 
hypertrophy, 102, 103 

and hypertension, 108 
murmurs in cardiac disease, 90 
stenosis, 91 
Cardiovascular asthenia, 94 
system, diseases of, 76 
examination of, 44 
by auscultation, 46 
by percussion, 45 
Carriers, diphtheria, 235 
Cartilaginous meatus, furunculosis of, 




Cataract, 170 

Catheterization, 147 

Catheters, 147 

Cecum and colon, tuberculosis of, 130 

Cellulitis, abscess and, differentiation, 

Cerebral artery, syphilitic thrombosis 
of, 176 

hemorrhage, coma from, postepileptic 
coma and, differentiation, 203 

lues, 203 
Cerebrospinal syphilis, 164, 169 
Cerumen, 181, 183 
Cervix, carcinoma of, 156 

examination of, 154 
Character of facies in examination of 

head, 35 
Charcot's fever, 137' 
Cheyne-Stokes breathing, 43 
Children, coma in, 205 

congenital syphilis in, 220 

convulsions in, 202 

examination of eyes of, 172 
Cholelithiasis, 136 
Chorda tympani, 178 
Chronic dyspepsia, 134 
Chvostek phenomenon, 197 
Cilio-spinal reflex, 164 
Claw hand, 189 

Clinical record, 21. See also History 
complete, 21 
environment, 22 
family history, 22, 23 
individuality, 23 
individual's state of health, 22 
Clubbing of fingers, in congenital 

heart disease, 92 
Coated tongue, 121 
Colic, renal, 127 
Collapsing pulse, 97 
Collection of data, 18 
Colon and cecum, tuberculosis of, 130 
Color, changes in, in extremities, 218 
Coma, 201, 203 

diabetic, 204 

from fracture of skull, 204 

in children, 205 

Coma, indirect ophthalmoscopy in, 172 

of acute alcoholism, 204 

pontile hemorrhage and, differentia- 
tion, 204 

postepileptic, coma from cerebral 
hemorrhage or poison and, differ- 
entiation, 203 

principal causes of, 206 

uremic, 204 
Combined sensation, testing, 201 
Complexes, 17 
Concentration, failure of, 116 

tests, 113 
Concomitant strabismus, 165 
Congenital heart disease, clubbing of 
fingers in, 92 

syphilis, 37 

in children, 220 
Conjugate deviation, 168 

movements of eye, 168 

palsy, 168 
Consensual reflex, 164 
Convergence, power of, 166 
Convulsions, 201 

conditions with which associated, 202 

epileptiform, 203 

in adults, 202 

in children, 202 

of lead-poisoning, 203 

unilateral, 169 
Coordination in lower extremities, loss 

of, 194 
Cor bovinum, 84, 98 
Corneal reflex, 198 
Corrigan pulse, 97 
Cranial nerves, 177 
Cremasteric reflex, 198 
Cretinism, 31 

and Frohlich's syndrome, S3 
Crossed paralysis, 180 
Cross-legged gait, 195 
Cutaneous reflexes, 198 
Cysts, ovarian, ascites and, differential 

diagnosis, 137 

Dactylitis, 220 
Data, assembling of, 20 
collection of, 18 



Data, incomplete, a source of error, in 
diagnosis, 32 
misinterpretation of, a source of error, 
in diagnosis, 32 
Deafness, 181 
nerve, 182 
Decompensation, cardiac, 95 
Decubitus, 35 

Deep sensation, testing, 201 
Defecation, 119 

Defective innervation of extrinsic mus- 
cles of eye, 165 
Deformities of extremities, 54, 220 
Degeneration, parenchymatous, of heart 

muscle, 1 01 
Dehydration, 132 
Delirium, indirect ophthalmoscopy in, 

Deltoid, strength of, testing, 189 
Dementia paralytica, 203 
Dermographism, 48 
Deviation, conjugate, 168 
Devitalized teeth, 121 
Diabetes, 170, 204 
Diabetic coma, 204 

Diagnosis, commoner sources of error 
in, 32 
theory of, 17 
use of tuberculin in, 232 
Diagram, Werner's, 167, 168 
Diarrheal diseases, 131 
Diet, 119 

Digestive disorders, causes, 117 
reflex, 134 
system, diseases of, 117 
examination of, 117 
abdomen, 124 
bowel action in, 119 
diet in, 119 
esophagus, 122 
feces, 131 

functional tests, 127 
mouth, 121 
pain in, 119 

psychic disorders in, 118 
radiographic, 127, 129 
rectum, 126 
vomiting in, 119 

Dilatation, cardiac, resultant to mitral 
disease, 95 
of pupil, maximal, solution for, 170 
of ventricles as cause of increase in 
size of heart, 89 
Diphtheria carriers, 235 
Schick test for, 235 
toxin for Schick test, 235, 236 
Diplopia, 165, 166 
Dipping, 139, 145 
Direct ophthalmoscopy, 171 
Diseases of cardio-vascular system, 
of digestive system, 117 
of geni to-urinary system, 144 
of respiratory system, 61 
Disorder of speech, 37 
Disseminated sclerosis, 187 
Dropped wrist, 189 

Drum membrane and auditory canal, 
inspection of, 213 
bulging of, 214, 215 
changes in, in disease, 214 

in structure, 216 
displacement of, 215 
normal, 213 
retraction of, 215 
Duodenal contents, extracting, technic, 
tug, 142 
Duroziez's murmur, 44 

sign, 98 
Dysarthria, 38 
Dyspepsia, chronic, 134 

Ear wax, 181 

Ears, examination of, 36, 212 

Edema, 212, 213 

Effusion, pericardial, 104, 105 
exploratory puncture in, 105 
simulating cardiac decompensation 
with tricuspid insufficiency, 99 

Egophony, 72 

Eighth cranial nerve, 180 
neoplasm of, 174 

Electric otoscope, 212 

Electrocardiogram, normal, 78 

Elephantiasis, 222 



Elevation of nipple due to carcinoma, 

Eleventh cranial nerve, 186 
Emotional expression, impairment of, 

Emptying stomach, fractional-extrac- 
tion method, 128 
Empyema, 73 

interlobar, 7$ 
Encephalitis lethargica, 169, 218 
Endocarditis, ulcerative, chart of, 46 
Environment, inability to adjust to, 23 

reaction to, 23 
Epigastric reflex, 198 
Epilepsy, 202, 203 

idiopathic, 203 
Epileptiform convulsions, 203 
Epiphysitis, 220 
Epithelioma, 38, 56 
Eserin, solution of, to avoid glaucoma, 

Esophagus, carcinoma of, with stenosis, 

examination of, 122 

stenosis of, 123 

stricture of, 123 
Examination, fluoroscopic, 129 

gynecologic, 152 

neurologic, 160 

of abdomen, 52, 124 

of breast, 227 

of cardio-vascular system, 44 

of ear and throat, 36, 212 

of esophagus, 122 

of external genitalia, 53 

of extremities, 54, 218 

of eyes, 36, 163 

of fallopian tubes, 158 

of feces, 131 

of fundus oculi, 170 
sequence in, 172 

of head, 35 

of heart, 44, 76 

of joints, 223 

of lungs, 61 

of motor system, 187 

of mouth, 37, 121 

of neck, 40 

Examination of nervous system, 54 
of nose, 37, 216 
of ovaries, 157 
of pelvic genitalia, 154 
of pleura, 70 

of post-nasal space and larynx, 216 
of prostatic secretion, 145 
of pulmonary system, 47 
of pupils, 163 
of rectum, 1 26 
of retinal arteries, in 
of sensory system, 199 
of spine, 225 
of teeth, 38 
of thorax, 40 
of tongue, 38 
of tonsils, 39 
of urine, 145 
of uterus, 154, 157, 158 
otoscopic, 181 
pelvic, 152 
physical, 30. See also 

Physical examination. 
proctoscopic, 149 
rectal, 148 
system, 61 
vaginal, 152 
Exploratory puncture in pericardial 

effusions, 105 
Expression, emotional, impairment of, 

External genitalia, inspection of, 53 
Extremities, examination of, 54, 218 

bone swellings, 221 

changes in color, 218 

character of infiltration of skin, 219 

deformities of, 220 

hyperesthesia, 220 

palpating lymph nodes in, 223 

peculiarity of gait in, 218 

swelling of joint, 221 

tremor, 222 

varicose ulcers, 220 
lower, loss of coordination in, 194 

segmental innervation of muscles 
of, 211 
upper, segmental innervation of mus- 
cles of, 210 



Extrinsic muscles of eye, defective 

innervation of, 165 
Eyeball, movements of, test for, 166 
Eyes, abnormal movements of, 169 

conjugate movements of, 168 

defective mobility of, 166 

examination of, 36, 163 

extrinsic muscles of, defective inner- 
vation of, 165 

fundus of, examination of, 170 
sequence in, 172 

nerves of, 165 

opacities of, 170 

visual fields, 173 

Face, asymmetry of, 178 

Facial hemiatrophy, progressive, 179 

nerve, 178 

motor root of, injury of, 179 

paralysis, 178, 186 
bilateral, 180 
pseudo, 178 
Facies, character of, in examination of 
head, 35 

tabetic, 165 
Factitious urticaria, 48 
Failure of concentration, 116 
Fallopian tubes, examination of, 158 
False fluctuation, 219 
Family history, 23 
Feces, acholic, 131, 132 

bacteriologic examination of, 134 

blood in, 133 

examination of, 131 

mucus in, 133 

parasites and ova in, 133 

pus in, 133 

putty colored, 132 
Fibrillation, auricular, 80, 81 
Fibrinous pleurisy, 70 
Fibroid nodules, subcutaneous, 221 
Fields, visual, 173 
Fifth cranial nerve, 177 
Finger nail, snapping, test, 199 

pleximeter, 41 
Fingers, clubbing of, in congenital heart 
disease, 92 

flexors of, testing, 188 

Flexors of fingers, testing, 188 
of wrist, testing, 189 

Flint murmur, 96 

Flora, intestinal, 134 

Fluctuation, false, 219 

Fluid in abdominal cavity, determina- 
tion of, 53 
in pericardial cavity, 90 
in pleural cavity, 71 

Fluoroscopic examination, 129 

Foul breath, 37 

Fractional-extraction method of empty- 
ing stomach, 128 

Fracture of skull, coma from, 204 

Fremitus, 49 

Friedreich's ataxia, articulation in, 187 

Frohlich's syndrome and cretinism, 33 

Fruity odor of breath, 37 

Functional tests for gastro-intestinal 
disease, 127 

Fundus of eyes, examination of, 170 
sequence in, 172 

Furunculosis of cartilaginous meatus, 
of meatus, mastoiditis and, in adults, 
differentiation, 212 

Gait, 194 

ataxic, of tabes dorsalis, 195 

cross-legged. 195 

hemiplegic, 194 

in hysteria, 195 

peculiarity of, 218 

scissor, 195 

steppage, 194 
Gall-bladder and kidneys, enlarged, 126 
Gall-stones, 134 
Gastric analysis, 120 

test meal, 127 
Gastro-intestinal tract. See Digestive 

Genitalia, external, inspection of, 53 
Genito-urinary diseases, vesical symp- 
toms in, 146 

system, diseases of, 144 
examination of, 152 
Glaucoma, 171 
Glossopharyngeal nerve, 184 



Glycosuria, 204 
Gordon's reflex, 199 
Graham-Steel murmur, 100 
Graves' syndrome, 35 
Grocco's sign, 72 
Gumma, 220 

ulcerating, 55 
Gums, lead line in, 122 
Gynecologic examination, 152 

Hair, 3$ 

Hallucinations of sound, 182 

Hand, claw, 189 

muscles of, atrophy of, 189 
Head, examination of, 35 
Headache, 170 
Head's zones, 200 
Hearing, acuity of, 181 

testing, 181 
Heart block, 77 

chronic valvular disease of, 93 
disease, congenital, clubbing of fingers 

in, 92 
examination of, 44, 76 
hypertrophy of, 84 
irritable, 94 
muscle parenchymatous degeneration 

of, 101 
size of, in cardiac disease, 84 

dilatation of ventricles in, 89 
fluid in pericardial cavity, 90 
location of apex impulse in, 86 
Hegar and Schultze's method in exami- 
nation of uterus, 157, 158 
Hematuria, 146 
Hemianopsia, 173 

Hemiatrophy, progressive facial, 179 
Hemic murmurs, 100 
Hemiplegia, 178, 180 
alternans, 191 

organic, hysterical and, differentia- 
tion, 192 
side-gait in, 195 
Hemiplegic gait, 194 
Hemorrhage, cerebral, coma from, post- 
epileptic coma and, differentiation, 
pontile, coma and, differentiation, 204 

Hip, tuberculosis of, 224 
Hippo era tic succussion in pneumo- 
thorax, 75 
History, family, 22, 23 
taking, family history, 26 

habits and environmental influ- 
ences, 28 
in acute complications of chronic 
disease, 26 
infections or intoxications, 24 
in chronic illness, 25 
order in recording, 29 
outline for, 24 
past history, 26 
present illness, 24 
Hoarseness, 40 

Hughlings Jackson syndrome, 186 
Hunger, air, 204 
Hutchinson's teeth, ^y, 39 
Hyperacusis, 182 
Hyperchlorhydria, 128 
Hyperesthesia of extremities, 220 

superficial, 200 
Hypernephroma of bones, 226 
Hypertension, no, in 

and hypertrophy, cardiac, 108 
due to chronic nephritis and uremia, 
Hypertrophy and hypertension, car- 
diac, 108 
cardiac, 84, 102 
Hypoglossal nerve, 186 

paralysis, unilateral, 187 
Hypophyseal tumor, 175 
Hysteria, 173, 202 
gait in, 195 

hyperesthetic areas in, 200 
Hysterical hemiplegia, organic and, 
differentiation, 192 
side-gait in, 195 

Idiopathic epilepsy, 203 
Immunological tests, 232 
Impairment of emotional expression, 

Incoordination, muscle, 193 
Indirect ophthalmoscopy, 172 
Inequality in pupils, 163, 164 



Inability to adjust to environment, 23 
Infiltration of skin, 219 
Ingestion of phenolphthalein, pigmenta- 
tion due to, 58 
Innervation, defective, of extrinsic 
muscles, 165 
segmental, of muscles of lower extrem- 
ity, 211 
of upper extremity, 210 
of trunk muscles, 209 
Inspection in physical examination, 34 
of anal region, 54 
of external genitalia, 53 
Insufficiency, aortic, 76, 91 
characteristic signs, 97 
mitral, 91 

accessory signs, 96 
of pulmonary valves, 10 
pulmonary, 91 
tricuspid, 91, 98 
valvular, 90 
Interlobar empyema, 73 
Interstitial keratitis, 170 
Intestinal flora, 134 
Intracranial aneurysms, 182 
lesions, localizing, 188 
pressure, increased, convulsions from, 
Irregularity, regular, of pulse, 79 
Irritable heart, 94 

Jackson's (Hughlings), syndrome, 186 
Jaw-jerk, 196 

Joints, examination of, 223 
swelling of, 221 

Kepler, 18 

Keratitis, interstitial, 170 

Kernig's sign, 206 

Ketonuria, 204 

Kidneys and gall-bladder, enlarged, 126 

in geni to -urinary diseases, 144 

tuberculosis of, 146 
Knee-jerk, 197 

Laennec, 17 
Lalling speech, 187 

Laryngeal palsy, 185 

Laryngismus stridulus, 202 

Larynx and post-nasal space, examina- 
tion of, 216 

Latissimus dorsi, testing, 190 

Lead line in gums, 122 

Lead-poisoning, 122 
convulsions of, 203 

Legs, muscular power of, testing, 190 

Leprosy, nodular, 39 

Lethargic encephalitis, 169, 218 

Leukoplakia, 121 

Light, good, necessary for physical 
examination, 34 
reflex, 164 

Limbs, deformity in, 54 

Limp, 218 

Liver, enlarged, 125 

Lobar pneumonia, diagnosis of, 63 

Loss of weight, 119 

Lower abdominal reflex, 198 

extremities, loss of coordination in, 

Lues, 36 

cerebral, 203 

Lumbar puncture, 206, 207 
needle, 207 
technic, 207 

Lungs, examination of, 61 
neoplasms of, 70 
perforations of, 74 
tuberculosis of, 66 
diagnosis of, 66 

Lymph nodes, palpating, in examina- 
tion of extremities, 223 

Lymphangitis, 220 

Lyon's tests, 129, 142 

Main en griffe, 189 
Maladjustment, 23 
Manson, 122 

Mastitis, acute, breast in, 231 
Mastoiditis, 212 

acute, 212 

furunculosis of meatus and, in adults, 
differentiation, 212 
Meals, test, 120 
gastric, 127 



Meatus, cartilaginous, furunculosis of, 

furunculosis of, mastoiditis and, in 

adults, differentiation, 212 
Melena, 133 
Mendel, 18, 233 
Meningismus, 206 
Meningitis, 169, 206 

tuberculous, 205 
Metastatic carcinoma, 226 
Meyer, 118 
Mitral insufficiency, 91 

accessory signs, 96 
stenosis, 91 

diagnosis, 93 

early, 94 

neurovascular asthenia simulating, 

Mobility of eyes, defective, 166 
Morgagni, 17 
Moro's cutaneous reaction, 233 

percutaneous test, 234 
Motor system, examination of, 187 
Mouth, examination of, 37, 121 
Movements, abnormal, of eyes, 169 

conjugate, of eyes, 168 
Mucus in stools, 133 
Murmurs, accidental, 100 

cardiac, in cardiac disease, 90 

Duroziez's, 44 

flint, 96 

Grahan-Steel, 100 

hemic, 100 

in diastole, conditions causing, 96 

timing, 44 
Muscle coordination, tests for, 193 

heart, parenchymatous degeneration 
of, 101 

incoordination, 193 
Muscles of hands, atrophy of, 189 

of lower extremity, segmental inner- 
vation of, 211 

of upper extremity, segmental inner- 
vation of, 210 

trunk, segmental innervation of, 209 
testing, 190 

Muscular power in legs and arms, 
testing, 190 
testing, 188 
Mydriasis, 36 
Myocardium, affections of, 101 

parenchymatous degeneration of, 101 
Myomata, uterine, 156 
Myosis, 36, 164 
Myositis ossificans, 225 

Nail, finger, snapping, test, 199 
Neck, examination of, 40 
Neck-sign, Brudzinski's, 206 
Negative Rinne, 181 
Neoplasm of eighth nerve, 174 

of lungs, 70 
Nephritis, 170, 203, 204 

chronic, 112 

concentration tests in, 113 
Nerve, acoustic, 180 

deafness, 182 

eighth cranial, 180 
neoplasm of, 174 

eleventh cranial, 186 

facial, 178 

fifth cranial, 177 

glossopharyngeal, 184 

hypoglossal, 186 

ninth cranial, 184 

olfactory, tests of, 177 

pneumogastric, 184 

recurrent laryngeal, paralysis of, 185 

seventh cranial, 178 

spinal accessory, 186 

tenth cranial, 184 

trigeminal, 177 

twelfth cranial, 186 

vagus, 184 
Nerves, cranial, 177 

of eyes, 165 
Nervous system, examination of, 54 
Neuritis, 201 

optic, 203 
Neurologic examination, 160 

clinical history and outline for, 160 
Neurovascular asthenia, 94 
Ninth cranial nerve, 184 
Nipple, bloody discharge from, 228 



Nipple, elevation of, due to carcinoma, 

Paget's disease of, 228 

retraction of, as sign of cancer, 228 

serous discharge from, 228 
Nodes, Parrot's, 221 
Nodular leprosy, 39 

syphilis, 55 
Nodules, subcutaneous fibroid, 221 
Normal blood pressure, 109 

electrocardiogram, 78 
Nose, examination of, 37, 216 

saddle, t>7 
Nuclear ophthalmoplegia, 169 
Nutrition, 35 
Nystagmus, 169, 183 

Objective manifestations, 17 
Ocular palsy, 169 
Olfactory nerve, tests of, 177 
Opacities of media, cornea and lens, 1 70 
Ophthalmoplegia, 169 

externa, 169 

interna, 169 

nuclear, 169 
Ophthalmoscopy, 170 

direct, 171 

indirect, 172 
Opium poisoning, 204 
Oppenheim's reflex, 199 
Opponens pollicis, strength of, testing, 

Optic neuritis, 203 

Organic hemiplegia, hysterical and, 
differentiation, 192 
side-gait in, 195 
Osier, 203 

Osteitis deformans, 218 
Osteoma, 226 
Osteomyelitis, 220 
Osteosarcoma, 226 
Otitis media, 212, 215 
acute catarrhal, 213 
purulent, 214 
Otoscope, electric, 212 
Otoscopic examination, 181 
Outline for taking histories, 24 
Ova and parasites in stools, 133 

Ovarian cysts, ascites and, differential 

diagnosis, 137 
Ovaries, examination of, 157 

Paget's disease, 218 

characteristics of, 227 
of nipple, 228 
Pain, 119 

abdominal, 140 
Palatal reflex, 198 

Palate, bilateral paralysis of, 186 
Palpation, 18 

of abdomen, 124 

of breast, 229 

of prostate, 150 
Palsy. See also Paralysis. 

Bell's, 179 

conjugate, 168 

laryngeal, 185 

ocular, 169 

pseudo facial, 178 
Pancreatic function, tests for, 129 
Papulo-pustular syphilid, 41 
Parallelism of visual axes, defect of, 166 
Paralysis. See also Palsy. 

abductor, 185 

adductor, 185 

agitans, manner of speech in, 187 

crossed, 180 

facial, 178, 186 
bilateral, 180 

hypoglossal, unilateral, 187 

of palate, bilateral, 186 

of recurrent laryngeal nerve, 185 

organic, functional and, differentia- 
tion, 192 

postdiphtheritic, 186 

pseudo, 221 
Paralytic squint, 166 
Parasites and ova in stools, 133 
Parenchymatous degeneration of heart 

muscle, 101 
Paresis, articulation in, 187 
Parkinson's disease, 218 
Parrot's nodes, 221 

Patterns of abdominal tumidity, 52 
Pectorals, testing, 189 
Pectoriloquy, 62 



Pelvic examination, 152 

position for, 153 
Percussion, 17 

in examination of pulmonary system, 

Percutaneous test, Moro's, 234 
Perforations of lungs, 74 
Pericardial cavity, fluid in, 90 
effusion, 104, 105 

exploratory puncture in, 105 
simulating cardiac decompensation 
with tricuspid insufficiency, 99 
sac, complete obliteration of, 107 
Pericarditis, 71 

acute fibrinous, 103 
Pericardium, adherent, 107 

diseases of, 103 
Periosteal reflexes, 196 

radial,. 196 
Periosteal-costal reflex, 197 
Peritonitis, early acute, 140 

tuberculous, 53 
Pharyngeal nerve, recurrent, paralysis 
of, 185 
reflex, testing, 39 
Phenol-sulphon-phthalein test, 115 
Phenolphthalein, pigmentation due to, 

Phenomenon, Chvostek, 197 
Physical examination, 30 
abdomen, 52 
by inspection, 34 
cardiovascular system, 44 
care, system and order in, $3 
extremities, 54 
head, 35 

outline for routine, 56 
pulmonary system, 47 
thorax, 40 
Pick's disease, 108 
Pigmentation due to ingestion of 

phenolphthalein, 58 
Pistol-shot pulse, 98 
Plantar flexion, 198, 199 
reflex, 198 

Babinski's, 192, 193, 199 
Pleu'ra, examination of, 70 
Pleural cavity, air in, 74 

Pleural cavity, fluid in, 71 

obtained from by puncture, 
examination of, 74 

Pleuris]/, fibrinous, 70 

Pleximeter fungi, 41 

Plumbism, 122 

Pneumogastric nerve, 184 

Pneumonia, lobar, diagnosis of, 63 
sequelae, 66 
tuberculous, diagnosis of, 64 

Pneumothorax, bruit d'airain of Trus- 
seau in, 75 
diagnosis of, 74 
Hippocratic succussion in, 75 

Pointing tests, 183 

Poisoning, lead, 122 
opium, 204 

Pontile hemorrhage, coma and, differ- 
entiation, 204 

Position for pelvic examination, 153 
for rectal examination, 148 

Positive Rinne, 182 
Weber, 182 

Post-auricular swelling, 212 

Postdiphtheritic paralysis, 186 

Postepileptic coma, coma from cerebral 
hemorrhage or poison and, differentia- 
tion, 203 

Post-nasal space and larynx, examina- 
tion of, 216 

Pott's disease, 225 

Power, muscular, testing, 188 
of convergence, 166 

Pressure, blood, normal, 109 
pulse, 84 

Progressive facial hemiatrophy, 179 

Proctoscopic examination, 149 

Prostate, palpation of, 150 

Prostatic secretion, examination of, 145 

Pseudo facial palsy, 178 
paralysis, 221 

Psychic disorders, 118 

Ptosis, 165 

Pulmonary insufficiency, 91 
stenosis, 101 

system, examination of, 47 
auscultation, 50, 51 
fremitus, 49 



Pulmonary system, percussion, 49 
voice transmission, 51 
valves, insufficiency of, 100 
valvular disease, 100 
Pulse, collapsing, 97 
Corrigan, 97 
deficit, 82 
in cardiac disease, 77 

acceleration of rate, 77 
auricular fibrillation, 80, 81 
dropped beats, 78 
irregularity of, 77 
pulse deficit, 82 

pressure, 84 
pulsus alternans, 83 
regular irregularity of, 79 
slowing of, 77 
pistol-shot, 98 
pressure, 84 

regular irregularity of, 79 
water-hammer, 97 
Pulsus alternans, 83 

Puncture, exploratory, in pericardial 
effusions, 105 
lumbar, 206, 207 
Pupils, abnormal contraction of, 164 
Argyll-Robertson, 36, 164 
cilio-spinal reflex, 164 
dilatation of, maximal, solution for, 1 70 
examination of, 163 
inequality in, 163, 164 
irregularity in shape, 164 
light reflex, 164 
mobility of, 163 

reaction to accommodation, 164 
size of, 163 
Pus in stools, 133 
Putty colored stools, 132 
Pyorrhea alveolaris, 38, 121 

Radial periosteal reflex, 196 
Radiographic examination of digestive 

system, 127, 129 
Reaction to environment, 23 
Record, clinical. See Clinical record. 
Rectal examination, 148 
position for, 148 

shelf, 149 

Rectum, examination of, 126 
Recurrent pharyngeal nerve, paralysis 

of, 185 
Reflex, abdominal, 198, 199 

corneal, 198 

Babinski's plantar, 192, 193, 199 

biceps, 196 

cilio-spinal, 164 

consensual, 164 

cremasteric, 198 

digestive disorders, 134 

diagnosis of diseases causing, 

diseases causing, 135 
epigastric, 198 

Gordon's, 199 

light, 164 

lower abdominal, 198 

Oppenheim's, 199 

palatal, 198 

periosteal-costal, 197 

pharyngeal, testing, 39 

plantar, 192, 193, 198, 199 

radial periosteal, 196 

triceps, 196 

viscero-cutaneous, 200 
Reflexes, 196 

cutaneous, 198 

periosteal, 196 

superficial, 198 

tendon, 196 
Regular irregularity of pulse, 79 
Renal colic, 127 
Resonance, skodaic, 72, ys^ 75 
Respiratory system, diseases of, 61 
Retinal arteries, examination of, in 
Retraction of drum membrane, 215 

of nipple as sign of cancer, 228 
Rheumatic infections, 36 
Rickets showing rosary, 34 
Riesman's method of timing murmurs, 

Rhine's test, 181 
negative, 181 
positive, 182 
Romberg's sign, 55, 194 
Rosary in rickets, 34 
Rotch's sign, 104 



Sabre-skin, 220 
Saddle nose, 37 
Sarcoma, 45 

of bones, 226 
Scanning speech, 187 
Schick test, 235 

combined reaction, 237 

diphtheria toxin for, 235, 236 

for detection of susceptibles to 

diphtheria, 235 
negative reaction, 236 
positive reaction, 236 
pseudo reaction, 236 
technic, 235 
Schultze and Hegar's method in exami- 
nation of uterus, 157, 158 
Scissor gait, 195 
Sclerosis, disseminated, 187 
Segmental innervation of muscles of 
lower extremity, 211 
of upper extremity, 210 
of trunk muscles, 209 
Sensation, combined, testing, 201 
deep, testing, 201 
superficial, testing, 200 
testing, 199 
Sense, astereognostic, 201 
of smell, test for, 177, 184 
of taste, testing, 178 
Sensory system, examination of, 199 
Serous discharge from nipple, 228 
Serratus magnus, testing, 190 
Seventh cranial nerve, 178 
Shelf, rectal, 149 
Sickness, sleeping, 169 
Side-gait in differentiation of organic 

and hysteric hemiplegia, 195 
Sign, Babinski's, 195 
Broadbent's, 107 
Brudzinski's neck, 206 
Duroziez's, 98 
Grocco's, 72 
Kernig's, 206 
Romberg's, 55, 194 
Notch's, 104 
Stellwag's, 36 
von Graefe's, 36 
Westphal's, 197 

Signs, 17 

Sinus arrhythmia, 78 

Skin, blanching of, in percussion, 42 

infiltration of, 219 
Skodaic resonance, 72, 73, 75 
Skull, fracture of, coma from, 204 
Sleeping sickness, 169 
Smell, sense of, 37 

test for, 177 
Snapping finger nail test, 199 
Snellen's type, 163 
Sound, hallucinations of, 182 
Spasmophilia, 202 
Speech, disorder of, 37 

lalling, 187 

scanning, 187 
Spinal accessory nerve, 186 
Spine, examination of, 225 
Spleen, enlarged, 126 
Sprue, 122 

Squint, paralytic, 166 
Steel- Graham murmur, 100 
Stellwag's sign, 36 
Stenosis, aortic, diagnosis of, 98 

cardiac, 91 

mitral, 91 
diagnosis, 93 
early, 94 

of esophagus, 123 

pulmonary, 101 

tricuspid, 91, 99 

valvular, 90 
Steppage gait, 194 
Stricture of esophagus, 123 
Stokes- Adams disease, 77 
Stomach, emptying, fractional-extrac- 
tion method, 128 
Strabismus, 165 

concomitant, 165 
Subcutaneous fibroid nodules, 221 
Subjective symptoms, 17, 18 
Superficial algesia, 200 

hyperesthesia, 200 

reflexes, 198 

sensation, testing, 200 
Surgical abdomen, acute, 140 
Swellings, bone, 221 

of joint, 221 



Swellings, post-auricular, 212 
Symptoms, 17 

subjective, 17, 18 
Syndrome, Frohlich's and cretinism, 33 

Grave's, 35 

Hughlings Jackson, 186 
Syphilid, nodular, 55 

papulo-pustular, 41 
Syphilis, cerebrospinal, 164, 169 

congenital, 37 
in children, 220 

inherited, 170 
Syphilitic thrombosis of cerebral artery, 

ulcers, 220 
System examination, 61 

Tabes, 201 

dorsalis, gait of, 195 
Tabetic athetosis, 201 

facies, 165 
Tachycardia, 77 
Taste, sense of, test for, 184 

testing, 178 
Technic of extracting duodenal contents, 

Teeth, devitalized, 121 

examination of, 38 

Hutchinson's, 37, 39 
Temperature test, 201 
Tendon reflexes, 196 
Tenth cranial nerve, 184 
Test, Babinski's, 192, 193, 199 

concentration, 113 

for muscle coordination, 193 

functional, for gastro-intestinal dis- 
ease, 127 

immunological, 232 

Lyon's, 129, 142 

meals, 120 
gastric, 127 

Moro's cutaneous, 233 
percutaneous, 234 

pointing, 183 

Rinne's, 181, 182 

Schick, 235 

sensation, 199 

temperature, 201 

Test, tuberculin, 232 
vestibular, 182 
Weber's, 181, 182 
Testing sensation, 199 
Tetany, 202, 217 

muscle irritability in, 197 
Theory of diagnosis, 17 
Thorax, examination of, 40 
by auscultation, 43 
by palpation, 40 
by percussion, 41 
technic, 40 
Throat, examination of, 212, 216 
Thrombosis, syphilitic, of cerebral ar- 
tery, 176 
Timing murmurs, 44 
Tinnitus, 182 
continuous, 182 
high pitched, 182 
low pitched, 182 
Tongue, carcinoma of, 121 
coated, 121 
examination of, 38 
Tonsillitis, 216 
Tonsils, diseased, 121 
enlarged, 216 
examination of, 39 
infected, 216 
Toxin, diphtheria, 235, 236 
Transdigital auscultation, 44 
Trapezius, testing, 190 
Tremor, 190, 222 
Triceps reflex, 196 
Tricuspid insufficiency, 91, 98 
stenosis, 91, 99 
valves, organic disease cf, 98 
Trigeminal nerve, 177 
Trunk muscles, segmental innervation 
of, 209 
testing, 190 
Tuberculin in diagnosis, 232 
tests, 232 
intradermic, 233 
Moro cutaneous, 233 
subcutaneous, 234 
Von Pirquet, 232 
Tuberculosis of breast, 231 
of cecum and colon, 130 



Tuberculosis of hip, 224 
of kidney, 146 

of lungs, characteristic lesion of, 67 
condition simulating, 69 
diagnosis of, 66 
presence of active lesion in, 67 
radiographic shadows in, 68, 69 
rales in, 68 
symptoms, 68 

tubercle bacilli in sputum, 68, 69 
Tuberculous meningitis, 205 
peritonitis, 53 
pneumonia, diagnosis of, 64 
Tubes, examination of, 158 
Tug, duodenal, 142 
Tumor, hypophyseal, 175 
Tumors, bone, 225 

benign, striae of, 226 
of breast, malignant, 231 
Twelfth cranial nerve, 186 
Type, Snellen's, 163 

Ulcerating gumma, 55 
Ulcerative endocarditis, chart of, 46 
Ulcers, syphilitic, 220 

varicose, of lower extremity, 220 
Unilateral convulsions, 169 

hypoglossal paralysis, 187 
Uremia, 203 
Uremic coma, 204 

odor of breath, 37 
Ureters, normal, 145 
Urine, examination of, 145 
Urticaria, factitious, 48 
Uterine myomata, 156 
Uterus, carcinoma of body of, 156 

examination of, 154, 157, 158 

Vaginal canal, examination of, 154 

examination, 152 
Vagus nerve, 184 
Valves, pulmonary, insufficiency of, 100 

Valves, tricuspid, organic disease of, 98 
Valvular disease, aortic, 97 
chronic, 93 
cause, 93 

diastolic murmur in, 93 
pulmonary, 100 
insufficiency, 90 
stenosis, 90 
Varicose ulcers of lower extremity, 220 
Ventricles, dilatation of, as cause of 

increase in size of heart, 89 
Ventricular predominance, 79 
Vertigo, 183 
causes, 184 

vestibular, differentiation between 
types, 184 
Vesical symptoms in genito-urinary 

diseases, 146 
Vestibular function, tests for, 183 
tests, 182 

vertigo, differentiation between types, 
Viscero-cutaneous reflex, 200 
Vision, acuity of, 163 
Visual axes, defect of parallelism of, 166 

fields, 173 
Vomiting, 119 
von Graefe's sign, ^6 
von Pirquet tuberculin test, 232 

Water-hammer pulse, 97 
Wax, ear, 181 
Weber's test, 181 

negative, 182 

positive, 182 
Weight, loss of, 119 
Werner's diagram, 167, 168 
Westphal's sign, 197 
Wrist, flexors of, testing, 189 
Wrist-drop, 189 

Zones, Head's, 200